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Home Care Plan and Activity Sheet for Week of_

Name (last, first) Diagnosis
Address
ZIP                     SS#            -        -
 
Personal  take temperature sponge bath by sink S M T W TH F S
Care bed bath shower
Regimen tub bath shampoo
groom hair denture care
mouth care foot care
nail care other:
special skin care:
bed sore care: A.
B.
C.
D.
special tube care:
dressing assistance assist with medicine
daily weight - record on calendar crush all pills
urine catheter. empty drainage bag other:
special bowel regimen note BM at right 
Dietary meal planning & preparation diet:
Functions feed: complete assist/partial assist note appetite at right
trouble swallowing   puree food
Activity assist with walking cane
assist transfer sitting to standing walker
assist transfer bed to chair don artificial limb:
Bed exercises - turn every 1- 2 hrs crutches
range of motion to limbs every 4 hrs hoyer lift
Special Therapies to follow (written plan): physical therapy
speech therapy
occupational therapy
other:
Household change linens make bed
light cleaning errands
essential laundry marketing
Additional Instructions:

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1999-2000; updates: 2002, 2004, 2005, 2007 Women's Heart Foundation, Inc. All rights reserved. Unauthorized use prohibited. The information contained in this Women's Heart Foundation (WHF) Web site is not a substitute for medical advice or treatment, and WHF recommends consultation with your doctor or health care professional.