Respite Care Check List
Patient _____________________ Social Security Number _____________ Birth date_________
Doctor______________________________ Phone __________ Location___________________
Hospital___________________ Phone ______________ Medical Insurance______________
Home/ Health/Hospice Patient?_______ Agency Phone_____________ Nurse_______________
Diagnoses________________________________________ How Long_________________
Characteristics of diagnoses affecting care ___________________________________________
Current Symptoms ____________________________________________________________
Allergies ____________________________________________History of seizures??_____
Patient's general emotional state (shy, sense of humor, weepy, sudden outbursts, etc)______________________________________________________________________
_____ Generally understand instructions
____ May not understand instructions
_____ Vision Limitations
Favorite distractions/Likes______________________________________________________
Dislikes_____________________________________________________________________
Universal Precautions instructions can be found _____________________________________
Vital Signs
____Don't need to take. ______ Take every ____ Hours. ______ Record date, time and reading on separate sheet of paper
____ Pulse _____ Blood Pressure ____ Respirations Temperature __under tongue__ Other
| MEDICATIONS | DOSE | TIME TO BE GIVEN | SPECIALS INSTRUCTIONS |
1. __________________________________________________________________________
2. __________________________________________________________________________
3. __________________________________________________________________________
Special Instructions
A. Give on Empty Stomach
B. Wake up patients to give Medications
C. With food/liquid (circle)
D. Give (time) before eating
E. Give on patient Request
F. Avoid ______________
G. Document when given
H. Other _____________
| Medical Equipment | When | Needs Assistance | Need to Know |
1. __________________________________________________________________________
2. __________________________________________________________________________
Appointments (doctor's office, physical therapy, beauty/barber, visit friends, ball game, etc.)
| To (Name) | Location | phone | Date | Time |
1. __________________________________________________________________________
2. __________________________________________________________________________
PERSONAL CARE AND COMFORT
Personal Care needs (attach instructions to this sheet)
| Catheter Care | Hearing aid | Shaving | Peri-Care | Mouth/Oral care |
| Bed Sores | Foley Bag | Dressings Changed | Hair/skin/nail care | Dentures |
Moving Patient
| Moves around unassisted | Transfers from bed to chair with assistance | Bedbound | Reposition | Requires Special life |
Special Instructions
Walking/transporting patients
| Unassisted | Cane | Walker | Wheelchair |
Physical Therapies
1. Unassisted
2. Needs Assistance
3. Range of Motion__________________________ Frequency ___________________
4. Special Exercises ________________________________________
Toileting
| Unassisted | Bedpan | Urinal | Catheter | Colostomy |
| Bedside Commode | Incontinent pads | other |
Bathing
| Bed bath | Shower | Tub | Needs assistance | __times per week |
Equipment needed
1. None
2. Transfer bench
3. Shower bench
4. Wheelchair
Bedroom Comfort
| Bedtime | Wake time | Nap time(s) | Room temperature | Closed windows |
| Prefers room dark |
Change Bed
| Pull sheet | Blankets(s) | Day__ or night__ |
Special bed items (sheepskin, egg crate mattress, extra pillows- attach sheet)
Food- for meals/snacks or special instructions, see attached list
| Needs Assistance feeding | Needs to be fed | Has difficulty swallowing | Takes nothing by mouth | Tube feeding |
| Soft foods | Record Liquid Intake |
Meal times___ Breakfast____Luch_____ Dinner_______Snack
Entertainment Options/preferences
| TV | Radio | Reading or being read to | cards | Other |
Avoid_________________________________________________________
HOUSE RULES AND INSTRUCTIONS
1. Locking Doors
2. Don't Smoke
3. Working Stove
4. Fireplace
5. Gas shut off valve
6. Fire Extinguishers
7. Guests
8. Pet Care guidelines
9. Neighbors
Other information____________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________
EMERGENCY PREPAREDNESS
Discuss 911 preferences_____________________________________________________
DNR Order or Advanced Directives can be found______________________________
I'll return home on____________________
I will be away from ________________________to________________________
Location___________________________________________Phone__________________
Friends and Relatives you can contact in an emergency
Name/address_____________________________________________ Phone____________
Name/address_____________________________________________ Phone____________
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