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Service Plan
Name of Client
Date of Birth
Address
Diagnosis
Client’s Functional Limitations
Types of Services Required
Nutritional Needs
Allergies
Services
Companion/Sitter
Personal Care Assistant
Nursing
Times of services
Frequency of Services
Duration of services
Describe how specific tasks are to be provided
Service starts on
Date
Regular Diet
Regular Diet
Yes
No
Special Diet
Special Diet
Low Salt
Low Fat
Low Cholesterol
Other
Special Treatments
DME/SpecialEquipment
Tub bath
Bed bath
Applying lotion to back
Behaviors that may interfere with delivering service
Goals and Objectives
Medications
Discharge Summary
Date of first Review
Supervisor Signature/Date
Client’s name/Responsible Party
Signature/Date
Submit
Nursing Assessment pg. 1 of 2
Client’s Name
Gender
Gender
Male
Female
Other
MR#
Date
Primary Diagnosis
Secondary Diagnosis
Other Pertinent Diagnosis
PCP Name
Other Physician Name
Prognosis
Prognosis
Poor
Guarded
Fair
Good
Excellent
Vital Signs (Height)
Weight
Temp
Pulse
Respiratory Rate (Resp)
Blood Pressure (B/P)
Allergies
Diet
Past Medical History
Support System Lives Alone?
Support System Lives Alone?
Yes
No
Legal Next of Kin
Next of Kin Phone Number
Family Composition
Caregiver’s Name
Caregiver’s Address
Caregiver’s Ability to Assist
Caregiver’s Ability to Assist
Personal Care
Mobility
Medication Admin
Meal Preparation
Safe/Clean Environment
Assist with Procedures
Days / Time Available
Comments
Advanced Directives Client has a Living Will?
Advanced Directives Client has a Living Will?
Yes
No
Special Provisions Included
Special Provisions Included
No Resuscitation
No Mechanical Ventilation
Medical Support Only
No Feeding Tubes
Other
(ADL) Needs Assistance With
Bathing
Toileting
Dressing
Transfers
Eating
Medication Reminders
Shopping
Housekeeping
Laundry
Other
Safety Hazards in Home
Sound Structure
Safe Placement of Cords, Rugs, Furniture
Adequate Heating & Ventilation
Safe Gas/Electric Appliances
Working Smoke Detectors
Fire Extinguisher in Home
Infestation of Pests
Neighborhood Safety
Other
Neurological / Mental Status
Alert/Oriented
Seizures
Memory Loss
Anxiety/Depression
Unsteady Gait
Weakness
Forgetful
Other
Risk Factors
Smoking
Obesity
Alcohol
Dependency
Drug Abuse
None
Other
Functional Limitations
Amputation
Paralysis
Endurance Issues
Poor Balance
Dyspnea
Vision Loss
Other
Assistive Devices
Cane
Walker
Wheelchair
Crutches
Other
Equipment Needed at Home
Hospital Bed
Nebulizer
Oxygen
Concentrator
Bath Chair
Hoyer Lift
Other
Fall Precaution Risk of Fall?
Fall Precaution Risk of Fall?
Yes
No
Cardiovascular
Cardiovascular
Pt. denies problems
Chest pain
Palpitations
Vertigo
Syncope
Pulse deficit
PVD
Cyanosis
Claudication
Varicose veins
Murmur
Fatigue
Edema
Cardiac pacemaker
Other
Cardiovascular Date
last date checked
Respiratory
Respiratory
Client denies problems Lung
clear
left
right
(wheezes/rhonchi, crackles/rales, diminish /absent)
Capillary refill less than 3 sec/ great than 3 sec
orthopnea
hemoptysis
SOB at rest/minimal exertion/moderate exertion/when walking > 20 feet
Cough productive/non-productive
Other
Gastrointestinal/abdomen
Gastrointestinal/abdomen
Pt. denies problems
Heartburn
Distention
Flatulence
Nausea
Vomiting
Constipation
Ascites
Cramping
Bleeding
Anorexia
Dysphagia
Diarrhea
Bowel incontinence
Other
Last BM
Ostomy
Submit
Nursing Assessment pg. 2 of 2
Patient’s Name
MR#
Date
Integument Assessment Skin
Integument Assessment Skin
Client denies problems
Color
Color
Normal
Pink
Pale
Cyanotic
Jaundiced
Turgor
Turgor
Poor
Fair
Good
Temperature
Temperature
Hot
Warm
Cool
Condition
Condition
Dry
Moist
Ecchymosis
Rasch
Petechie
Iitch
Redness
Bruises
Scaling
Comment
Open wound/decubitus/incision/diabetic ulcer location
Describe
Skin Problems
Lesion
Scaling
Lesion
Wound
Ulcer
Incision
Petichie
Rasch
Ostomy
Cyst
Masses
Itch
Other
GU/GYN
Pt. denies problems
Frequency
Urgency
Incontinence
Nocturia
Polyuria
Dysuria
Oliguria
Pain
Burning
Odor
Lithiasis
Hematuria
Infections
Ostomy
Musculoskeletal
Pt.denies problems
Fracture
Contracture joints
Atrophy
Decreased ROM
Pain: location
Intensity
Intensity
1
2
3
4
5
6
7
8
9
10
Duration
Duration
Less often than daily
Daily, but not constantly
All of the time
Pain Assessment : Area
What makes pain better?
What makes Pain Worse?
Medication taken for Pain and frequency
Eye
Eye
Pt. denies problems
Impaired vision
Cataracts R/L
Retinopathy
Blind R/L
Legally blind
Glasses
Contacts R/L
Blurred vision
Prothesis R/L
Glaucoma
Other
Nose
Nose
Pt.denies problems
Congestion
Epistaxis
Loss of smell
Sinus problem
Other
Throat
Throat
Pt.denies problems
Dysphagia
Hoarseness
Lesions
Ssore throat
Other
Mouth
Mouth
Pt. denies problems
Dentures upper/lower/partial/total
Gingivitis
Toothache
Ulcerations
Other
Communication Assessment Primary Language
Language Barrier
Language Barrier
Caregiver
Patient
Interpreter Needed
Interpreter Needed
Yes
No
Hearing Loss
Hearing Loss
Yes
No
Aide Used
Aide Used
Yes
No
Ear Discharge or Pain
Ear Discharge or Pain
Yes
No
Visual Impairment
Visual Impairment
Blind
Glasses
Contacts
Redness/Itching/Burning
Reading/Writing Problems
Reading/Writing Problems
Patient
Caregiver
Slow Learner
Slow Learner
Patient
Caregiver
Comments
(ADLs) Ambulation
(ADLs) Ambulation
Unable to Do
Minimal Assistance
Moderate Assistance
Maximal Assistance
Independent
Stairs
Stairs
Unable to Do
Minimal Assistance
Moderate Assistance
Maximal Assistance
Independent
Dressing
Dressing
Unable to Do
Minimal Assistance
Moderate Assistance
Maximal Assistance
Independent
Feeding
Feeding
Unable to Do
Minimal Assistance
Moderate Assistance
Maximal Assistance
Independent
Household Tasks
Household Tasks
Unable to Do
Minimal Assistance
Moderate Assistance
Maximal Assistance
Independent
Transfer
Transfer
Unable to Do
Minimal Assistance
Moderate Assistance
Maximal Assistance
Independent
Self Care
Self Care
Unable to Do
Minimal Assistance
Moderate Assistance
Maximal Assistance
Independent
Toileting
Toileting
Unable to Do
Minimal Assistance
Moderate Assistance
Maximal Assistance
Independent
Reviewed and Discussed with Patient/Caregiver
Services provided
Frequency and Duration of Service
Goals of Service
Complaint Rights and Procedures
Patient Rights/Responsibilities/State Hotline No.
Home Safety/Emergency Info
Reporting Abuse/Neglect/Exploitation
Agency Drug-Free Work Policy
Confidentiality/Release of Records Policy
Patient/Caregiver participated in the development of Care Plan
Other
R.N. Name
R.N. Signature
Date
Optional: Medications / Comments
Submit
