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© Kinnser Software 2016. Aide Care Plan Page 1 of 2  

Aide Care Plan

Clinician:

Patient Name (Last Name, First Name) & MRN: Mileage: Gender:

Agency Name/Branch:

☐ M ☐ F  

 

Date: / /

Time In: Time Out: DOB: / /

Functional Limitations

☐ Amputation ☐ Paralysis ☐ Legally Blind ☐ Hearing ☐ Bowel/Bladder Incontinence

☐ Endurance ☐ Dyspnea ☐ Contracture ☐ Ambulation ☐ Speech

Other:

DME

☐ Bedside Commode   ☐ Cane   ☐ Hospital Bed   ☐ Grab Bars   ☐ Elevated Toilet Seat  

☐ Nebulizer   ☐ Oxygen   ☐ Wheelchair   ☐ Walker   ☐ Tub/Shower Bench  

Supplies

☐ ABDs ☐ Ace Wrap   ☐ Alcohol Pads   ☐ Chux/Underpads   ☐ Diabetic Supplies  

☐ Drainage Bag ☐ Dressing Supplies   ☐ Duoderm   ☐ Exam Gloves   ☐ Foley Catheter  

☐ Gauze Pads ☐ Insertion Kit   ☐ Irrigation Set   ☐ Irrigation Solution   ☐ Kerlix Rolls  

☐ Leg bag ☐ Needles   ☐ NG Tube   ☐ Probe Covers   ☐ Sharps Container  

☐ Sterile Gloves ☐ Syringe   ☐ Tape  

Other:

Activities Permitted

☐ Complete Bed Rest ☐ Up as Tolerated   ☐ Exercise Prescribed   ☐ Cane   ☐ Independent at Home  

☐ Bed Rest with BRP ☐ Transfer Bed-Chair   ☐ Wheelchair   ☐ Crutches   ☐ Partial Weight-Bearing  

☐ Walker  

Other:

Vital Sign Notification

BP Systolic >   <                                Pulse  >     <   Respiration  >     <      

BP Diastolic >   <    Temperature  >     <                ☐ No Bowel Movement in 3 Days  

Foley:     Weight Gain or Loss:    

Aide Care Plan

Patient Name (Last Name, First Name) & MRN: Date:

/ /

                           

© Kinnser Software 2016. Aide Care Plan Page 2 of 2

 

Vital Signs Frequency Household Frequency

Blood Pressure     Change Linen    

Pulse     Light Housekeeping    

Respiration     Make Bed    

Temperature     Personal Care  

Weight     Assist of Dress    

   Elimination     Back Rub/Massage    

Assist w/ Bed Pan     Check Pressure Areas    

Assist w/ Bedside Commode     Comb Hair    

Catheter Care     Complete Bath    

Empty Ostomy Bag     Foot Care    

Incontinent Care     Nail Care    

Record Bowel Movement     Oral Hygiene Denture Care    

   Activity     Partial Bath/Sponge    

Assist in Ambulation     Pericare    

Assist in Transfer     Shampoo Hair    

Range of Motion     Shave    

Turn or Position     Skin Care    

  Tub/Shower    

  Universal Precautions    

Additional Comments