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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