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Sample Senior Care Plan
Client: Jane Doe Client#: 2000
Address: 100 W. Main Street, #501, Chicago, IL 60606
Directions: (Include directions for driving by car or traveling by public transportation including bus numbers).
Caregiver Staffing Requirements: Caregiver must have driver’s license to run errands
Telephone Number: 000-000-0000
Emergency Contact Information
Medical Emergency: 9-1-1
(Always call 9-1-1 first if there is an urgent medical condition).
Doctor: Name, Address, Phone
Pharmacy: Osco Drug PH: 000-000-0000
(Does Pharmacy Deliver? If not, suggest one that does)
Lifeline Necklace: 800-000-0000
Medicare Covered Physical Therapy: Mon, Wed, Fri, from 2pm – 4pm
Family Contacts:
1) Neighbor: Joan Smith, PH: 312-000-0000
2) Son: John Doe, PH: 312-000-0000
Care Service Arrangements
Service Plan:
❑ Monday: 9:30AM – 12:30PM
❑ Tuesday: 9:30AM – 12:30PM
❑ Wednesday: 9:30AM – 12:30PM
❑ Thursday: 9:30AM – 12:30PM
❑ Friday: 9:30AM – 12:30PM
❑ Saturday: 9:30AM – 12:30PM (When requested)
❑ Sunday: 9:30AM – 12:30PM (When requested)
Note: Family usually stops by on weekends but if they are unable to do so, may request a Caregiver.
Services to be Performed:
❑ Monitor medication schedule
❑ Assist with meal planning and preparation
❑ Monitor morning shower and assist with dressing
❑ Assist with physical therapy routine
❑ Maintain clean household: clean bathroom, kitchen, vacuum, dust, help water plants, take out garbage
❑ Engage in conversation and mental stimulation (likes daily crossword puzzle in newspaper)
❑ Escort to Beauty Salon on Friday morning
❑ Laundry in basement: change and launder bed linens
❑ Maintain updated calendar (Children will escort to doctor’s appointments approximately every two weeks)
Meals: Encourage nutritious eating and low sodium intake
Breakfast: Instant Carnation breakfast
Lunch: Soup or grilled cheese sandwich (something light)
Dinner: Prepare main course entrée for reheating later
Personal Profile
Name: Jane Doe Age: 83 Birthday: 2/15/1926
Height: 5’3” Weight: 115 lbs.
Medical Conditions: Fibromyalgia, Thyroid condition, Spinal Stinosis (treated with steroids), blood pressure erratic which has caused some dizziness. Blood pressure is the most serious medical condition currently and blood count was found to be too low and received 3 blood transfusions during recent hospitalization. Received new medications to monitor blood pressure and doctor wants to monitor effectiveness of these medications.
Activities of Daily Living: Eyeglasses to read, Upper Dentures, walks without assistance, monitoring only for bathing, motivate/monitor exercises
Goals:
❑ Take medications as scheduled
❑ Healthy and nutritious eating
❑ Exercise: follow prescribed physical therapy routine
Interests:
❑ Enjoys playing golf at Country Club
❑ Enjoys knitting and indoor/outdoor flower garden
❑ 1 son: John, lives in New York
❑ 3 grandchildren
❑ 2 great grandchildren
❑ Worked as Administrative Assistant
❑ Enjoys friendships with life-long girlfriends living on the same street
Monitor Medications: Cousin is R.N. and fills pillboxes for two-weeks.[pic]
|Medication |Dosage |Time |Frequency |Treatment For: |
| | | | | |
|Restoril (Temazepam) |15mg |Bedtime |1x Daily |Sleeping Aide |
| | | | | |
|Effexor XR |150mg |Daily: AM |1x Daily |Depression |
| | | | | |
|Fergon |325mg |2x Daily: AM, PM |2x Daily |Iron Tablet |
| | | | | |
|Pepcid |20mg |2x Daily: AM, PM |2x Daily |Stomach Nausea |
| | |(As needed) | | |
| | | | | |
|Miacolm Nasal Spray |1 Spray |Daily: 1X |1x Daily |Bones/Osteoporosis |
| | | | | |
|Reglan |5mg |With meals and at bedtime |With meals |Constipation/Nausea |
| | | | | |
|Klonopin |1mg |Bedtime |1x Daily |Sleep/Anxiety |
| | | | | |
|Buspar |15mg |Daily: AM, Noon, PM |3x Daily |Restless Legs |
| | | | | |
|Cozaar |5mg |Daily |1x Daily |Blood Pressure |
| | | | | |
|Synthroid |75mg |Daily |1x Daily |Thyroid |
| | | | | |
|Amoxycillin |500mg |2x Daily: AM, Noon |3x Daily |Bladder Infection |
| | | | | |
|Provigel |50mg |Daily: AM |1x Daily |Fatigue |
| | | | | |
|Vetrom |50mg |3x Daily: AM, Noon, PM, As Needed |3x Daily |Pain: As needed |
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