PERSONAL CARE

Bed BathPartial BathShowerTub BathOral Hygiene / Denture CareShampooComb / Brush / Dry Hair

TOILETING

Uses BathroomUses BedpanUrinalDiapers / DependsNight Time Care
Freq

SLEEPING PATTERN:

Walking Hour/s:


Sleeping Hour/s:

HOMEMAKING

Meal Preps:

BreakfastLunchDinnerSnackDishes

HOUSEKEEPING

Linen ChangeLight LaundryKitchen UpkeepBathroomBedroomGrocery ShoppingErrands
Others:

TREATMENTS

Temperature
Oral:


Temporal:


Axillary:


Bld. Pressure
Reading:


Bowel and Bladder Fxn. Specify:


CatheterOstomy Bag

ACTIVITIES

Up as ToleratedTransfer BoardHoyer Lift

Ambulation:

With Full AssistCaneCrutchesWalkerWheel Chair

Bedrest:

Complete w/ Toilet PrivilegesComplete w/o Toilet PrivilegesTurn & RepositionUse Commode ChairBed / Fracture Pan

Exercise:

Range of Motion as taught by RN/PTActive ROMPassive ROM
Others:


Drivin Freq:


Destination: