Care Plan
|[pic] |Public Health Division |[pic] |
| |HIV/STD/TB Program | |
| |HIV Community Services | |
| |Care Plan | |
| |"Confidential ( this form must always be saved on a secure network accessible only by Ryan White | |
| |funded staff." | |
| | | |
|Client name: | | |Care plan date: | / / |
|Problem/primary barriers (check all that apply) |
| Health insurance/ | Transportation | Self sufficiency | Nutrition |
|medical coverage |No personal transportation |Burned bridges |Wasting syndrome |
|No insurance/medical coverage |Unable to pay for |Communication issues |Problems with nutrition |
|Disability determination |personal transportation |Difficulty w/follow-through |Severe problems eating |
|Lack of eligibility documents |Mental health |Unable to fill out own forms |Adherence |
|Housing |Depression |Needs financial assistance |Lacks a regular schedule |
|Housing in jeopardy |Social/emotional support |Medical needs |Medication side effects |
|Homeless |Discrimination |Poor health |Doubts med. effectiveness |
|Basic needs |Willing to get help, |Needs HIV care referral |Complex regimen |
|Lack food |none available |Needs treatment for |Knowledge of HIV disease |
|Difficulty accessing assistance |Unwilling to get help |non-HIV condition |Little understanding |
|Lack of household/ |Addictions |Medical emergency |No understanding |
|personal items |Willing to get help, |Oral health |Other |
|Work related issues |none available |No regular dentist |Care giving responsibilities |
|Home support/activities |Unwilling to get help |Current tooth/gum pain |Child care/child welfare |
|of daily living |Risk reduction |Difficulty eating/talking | |
|Language |High risk behaviors | | |
|Legal |No understanding of risks | | |
| |Undisclosed HIV status | | |
| | | | | |
| | | | | |
| | | | | |
|Prioritized issues/problem descriptions |
| |
|Tasks/description |Owner |Target date |Completion date/outcome |
| | | / / | / / - |
| | | / / | / / - |
| | | / / | / / - |
| | | / / | / / - |
| | | / / | / / - |
| | | / / | / / - |
(Optional) client signature may be obtained based on the discretion of the case manager. Case manager signature is required.
Client’s responsibility/agreement: I have participated in the creation of this plan for my care. I understand that I have to take responsibility for MY plan in order for the plan to succeed. My case manager/health advocate has explained to me what portions of the plan I am solely responsible for and those that my case manager/health advocate will assist me with. I agree to follow all aspects of this plan and advise my case manager/health advocate if there are significant changes in my life that make it necessary to change this plan. I agree to stay in contact with may case manager/health advocate as planned. My case manager/health advocate has discussed with me the consequences if I don’t keep this agreement.
|Client signature | |Date | / / |
| |
|Case manager signature | |Date | / / |
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- care plan for mitral regurgitation
- nursing care plan for ineffective tissue perfusion
- care plan for suprapubic catheter
- hospice care plan goals template
- hospice care plan template
- hospice care plan samples
- hospice social work care plan examples
- social work care plan template
- hospice nursing care plan goals
- social worker care plan examples
- psychosocial nursing care plan examples
- care plan for psychosocial needs