ASSESSMENT AND NEGOTIATED CARE PLAN
NEGOTIATED SERVICE AGREEMENT
Facility name: Date entered: _______________ Current date: ________________
Client’s name: Date of birth: __________ Age: _____ Language(s) spoken
Name of interested party (POA, guardian, or family): Phone (H): (W):
Address of person listed above:
Physician’s name: Phone #:
Advanced directive/Living will/Legal Documents ( yes ( no Type: ________________
|Medical History: |Current Medical Status: |
| | |
| | |
| | |
| | |
| | |
|Dressing |What client prefers to do independently |What provider/support person does/When |
|Indep Assist Depend | | |
|( ( ( | | |
|Day time wishes: | | |
| | | |
| | | |
|Nighttime wishes: | | |
| | | |
|Personal Hygiene | | |
|Indep Assist Depend | | |
|( ( ( | | |
|How often? | | |
| | | |
|When? | | |
| | | |
|Time required: | | |
| | | |
|Preferences: | | |
|Bathing |What client prefers to do independently |What provider/support person does/When |
|Indep Assist Depend | | |
|( ( ( | | |
|How often? | | |
| | | |
|When? | | |
| | | |
|Time/equipment needed: | | |
| | | |
|Preferences: | | |
|Eating | | |
|Indep Assist Depend | | |
|( ( ( | | |
|Special diet? | | |
| | | |
|Eating habits: | | |
| | | |
|Food allergies: | | |
| | | |
|Equipment needed: | | |
| | | |
|Wishes: | | |
|Toileting | | |
|Indep Assist Depend | | |
|( ( ( | | |
| | | |
|Urinary problems? | | |
| | | |
|BM control? | | |
| | | |
|Needed equipment: | | |
| | | |
|Wishes: | | |
| | | |
|Mobility/Transfers |What client prefers to do independently |What provider/support person does/When |
|Indep Assist Depend | | |
|( ( ( | | |
|Adaptive equipment? | | |
| | | |
|Extra transporting support? | | |
| | | |
|Preferences: | | |
|Positioning | | |
|Indep Assist Depend | | |
|( ( ( | | |
|Equipment/supplies? | | |
| | | |
|Preferences: | | |
|Communication/Visual | | |
|Visual problems: ( yes ( no | | |
| | | |
|Hearing problems: ( yes ( no | | |
| | | |
|Able to express self: ( yes ( no | | |
|Comments: | | |
| | | |
|Medication | | |
|Indep Assist Administer | | |
|( ( ( | | |
| | | |
|Schedule: | | |
| | | |
|Allergies: | | |
| | | |
|Preferences: | | |
|Pleasurable Activities |What client prefers to do independently |What provider/support person does/When |
|Indep Indvidual Group | | |
|( ( ( | | |
|Preferences: | | |
| | | |
| | | |
| | | |
|Nursing Services |DESCRIBE NURSING SERVICES PROVIDED: |DESCRIBE NURSE DELEGATED TASKS: |
|Yes No | | |
|( ( | | |
| | | |
| | | |
|Behavioral Issues | | |
|Yes No | | |
|( ( | | |
|Describe: | | |
| | | |
| | | |
|Leaving the Home | | |
|Can client leave home independently? | | |
|Yes No | | |
|( ( | | |
| | | |
|If no, describe methods to maintain safety: | | |
| | | |
| | | |
Health issues to monitor:
Volunteer services provided/when:
Contractors utilized/services/when:
Physical enablers:
NOTES:
SIGNATURE PAGE – NEGOTIATED SERVICE AGREEMENT
Date of original plan:
Signatures:
|Provider/Owner: |Date: |Review Date: |Review Date: |
|Client: |Date: |Review Date: |Review Date: |
|Client Representative: |Date: |Review Date: |Review Date: |
|Client Representative: |Date: |Review Date: |Review Date: |
|Caregiver: |Date: |Review Date: |Review Date: |
|Health Professional (if applicable): |Date: |Review Date: |Review Date: |
|Case Manager (if applicable): |Date: |Review Date: |Review Date: |
|Other Participant: |Date: |Review Date: |Review Date: |
INFORMATION WITHIN THIS DOCUMENT IS CONSISTENT WITH REQUIREMENTS IN WAC 388-78A
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