All names and numbers are fictitious.  Any similarity to to any real persons is purely coincidental   

Date: November 20, 03              My Caring Agency                    Page:  1

Service/Care Plan (10)         from 00/11/20 to 00/12/18     Review: 01/02/20

Client Name: SCHULTZ, BoB                                  Phone #: (403) 555-6379

    Address: 3677 - 64 Street                        Area/Desk: 1  

             Edmonton, AB                  Referral:            (403) 555-6666

                                                    Pauline Brewer           

             T7G P7R                                MISERICORDIA             

Emerg. Cont:         555-5766                                                 

  Physician: Dr Brown                                                        

  Diagnosis: Knee Surgery                                  Marital:          

                                               Gender:  female                

                                            BirthDate:1956/02/04             

______________________________________________________________________________

Introduction:                                                

   Doraline has just been released from hospital following knee surgery and    required helpwith rehabilitation and care until she is mobile.              

Medication(s):                            

   Tylenol for pain.                                                        

Plan:

1. HC: Home Care                                                  

      Staff will provide basic cleaning and meal prep for the first week only.

   a) VACUUMING                                                  

         Vacuum all floors daily.

   b) DUSTING                                                    

         Dust furniture weekly

   c) WASH FLOORS                                                

         Wash kitchen and bathroom floors on Friday morning after shopping.

   d) BATHROOM                                                    

         Assist patient to bathroom as needed.

   e) MEAL PREPARATION                                           

         Prepare lunch and supper in the morning.  Put the supper in the freezer for patient to reheat after you have gone

   f) SHOPPING                                                   

         check refrigerator daily and make a list of items needed.  Purchase items on Friday morning after morning bath.

Outcome/Goal:

      Reassess the progress of the patients mobility after one week.

Summary:                                  

   Recovery to self sufficiency should take three weeks. Reassess at that time.

Authorized Signature:__________________________  Date: ______________