EmailMe Form - Client Weekly Care Plan

Client's First Name:

Client's Last Name:

Your Name (What you call yourself):

Week Ending Date (This is ALWAYS a Saturday):

Ambulation

Assist to Walk:

Escort on Walk:

Sedentary During Visit:

Assist with Transfer:

Safety Monitoring:

Other/Comments (Ambulation): *

Grooming

Grooming Reminder:

Supervised/Queued Grooming:

Hair Combing:

Shaving:

Hearing Aid Assistance:

Assistance with Dentures:

Assist with Oral Hygiene:

Assist with Glasses:

Other/Comments (Grooming): *

Dressing

Dressing Reminder:

Assist with Clothing Choices:

Special Garments:

Name of Garment *

Upper Body Dressing:

Lower Body Dressing:

Shoes/Socks/Elastic Stockings:

Other/Comments (Dressing): *

Bathing

Bathing Reminder:

Assist with Water Temperature:

Stand-by Shower:

Assisted Bath:

Type of Assisted Bath:

Sponge

Bed

Shower

Tub

Shampoo Hair:

Other/Comments (Bath): *

Toileting

Toileting Reminder:

Toileting Assistance:

Diaper/Pad Change:

Other/Comments (Toileting): *

Skin Care

Massage the Skin:

Rub Pressure Points:

Apply Cream (PER SERVICE PLAN ONLY!)

Other/Comments (Skin Care): *

Medication Reminders:

Medications, over-the-counter or prescription, cannot be counted, measured, or poured by CareTrak Staff.

AM Medications:

PM Medications:

Other/Comments (Medications): *

Meals

Meal Preparation

Breakfast:

Lunch:

Dinner:

Snack:

Assist to Eat/Feed:

Other/Comments (Meals): *

Housekeeping

Sunday Housekeeping:

Monday Housekeeping:

Tuesday Housekeeping:

Wednesday Housekeeping:

Thursday Housekeeping:

Friday Housekeeping:

Saturday Housekeeping:

Personal Affairs

Grocery Shopping:

Errands:

Transport in Client's Car:

Transport in Employee Car:

Accompany Client:

Who Drove?

Client

Employee

Public Transportation

How did this week's visit(s) go? How was the client? *

Visit Summary

Good Day/Client Comfortable:

Average Day:

Poor Day/Client Feeling Poorly:

Other/Comments (Personal Affairs): *

Hospice Clients Only

Sunday Meals:

Breakfast:

Lunch:

Dinner:

Snack:

Fluid Intake:

Monday Meals:

Breakfast:

Lunch:

Dinner:

Fluid Intake:

Tuesday Meals:

Breakfast:

Lunch:

Dinner:

Fluid Intake:

Wednesday Meals:

Breakfast:

Lunch:

Dinner:

Fluid Intake:

Thursday Meals:

Breakfast:

Lunch:

Dinner:

Fluid Intake:

Friday Meals:

Breakfast:

Lunch:

Dinner:

Fluid Intake:

Saturday Meals:

Breakfast:

Lunch:

Dinner:

Fluid Intake:

Outputs

Hospice Patients Only. For bowel movements, note time of day as well as type (normal, diarrhea, etc.) and color. For urination, note color, odor, burning sensation etc..

Sunday Bowel Movements (BM):

Sunday Urination:

Monday BM:

Monday Urination:

Tuesday BM:

Tuesday Urination:

Wednesday BM:

Wednesday Urination:

Thursday BM:

Thursday Urination:

Friday BM:

Friday Urination:

Saturday BM:

Saturday Urination:

For Live-In Clients Only

Provide time of night that the client woke up and amount of time spent with the client. For Example, 8:00 p.m. - 8:20 p.m.)

Sunday Night Sleep Interruptions:

Monday Night Sleep Interruptions:

Tuesday Night Sleep Interruptions:

Wednesday Night Sleep Interruptions:

Thursday Night Sleep Interruptions:

Friday Night Sleep Interruptions:

Saturday Night Sleep Interruptions: