Sample Care PlanActivities of Daily Living (ADL's) BathingHas your ability to bathe independently worsened in the past years? Yes/No Do you have difficulty bathing? Yes/No What are the problems you're expecting with bathing?
Problems:Difficulty getting to the bathroom Bathroom/Sink Upstairs Can't reach behind body to wash Can't get into tub/shower Can't stand in shower Don't remember to wash Other, please describe Bathing Assistance Used:Special Shower Head Seat in the shower Support Bars Special extension brushes Footing device in tub or shower, reduction of slipping Assistance from aide Other, please describe Recommended AssistanceSpecial Shower Head Seat in the shower Support Bars Special extension brushes Footing device in tub or shower, reduction of slipping Assistance from aide Other, please describe PGCM Assessments:No difficulty Some difficulty Moderate/significant difficulty Gets partial assistance (one body area, task, or process only) Assistance with 2 or more body areas, tasks, or processes DressingHas your ability to dress independently worsened in the past years? Yes/No Do you have difficulty dressing? Yes/No What are the problems you're expecting with dressing?
Problems:Difficulty reaching behind body Difficulty bending over Difficulty with buttons, hand problems Difficulty with zippers, hand problems Poor vision No clean clothes, can't do laundry Difficulty with shoes and socks Difficulty changing clothes Other, please describe Bathing Assistance Used:Velcro Large buttons or zippers Mechanical devices for helping get on clothes/shoes Washer on first floor Assistance from aide Other, please describe
Recommended Assistance:Velcro Large buttons or zippers Mechanical devices for helping get on clothes/shoes Washer on first floor Assistance from aide Other, please describe PGCM Assessments:No difficulty Some difficulty Moderate/significant difficulty Gets partial assistance (one body area, task, or process only) Assistance with 2 or more body areas, tasks, or processes |