Client 177322
Effective 4-7-2025
The client is a 75-year-old woman living independently in senior housing. She is alert, oriented, and currently recovering from recent back surgery. She has a history of falls and ambulates with a walker. Her fall risk is influenced by drop foot and post-surgical weakness, requiring consistent attention to balance and mobility.
The client manages her medications independently and remains as self-sufficient as possible. She benefits from standby supervision for safety, along with hands-on assistance as needed for daily tasks. Caregivers should stay observant, anticipate potential instability, and provide support promptly to reduce fall risk.
Maintaining independence is important to the client, and she actively participates in directing her care. At the start of each shift, caregivers should check in with the client to understand her priorities and preferred level of assistance. Support should align with her goals while ensuring safety at all times.
The overall goal of care is to support Jean's recovery, maximize her independence, and minimize risk while allowing her to remain safely in her home.
Schedule is based on Jean's needs and preferences.
The client directs her care. Caregivers should ask the client at the start of each shift what she would like help with and support her priorities for the day.
Date: 3/31/26
The client is doing well. Her mobility has improved; however, she continues to have difficulty with mobility and generalized left-sided weakness.
The client reported a fall last week with no injuries. She reported losing her balance. Continue to monitor for fall risk and provide standby assistance as needed.
The client receives informal support from a friend who is also listed as her emergency contact.
Add to chore list:
Specify transportation to:
All other tasks remain unchanged from the current care plan.
CP Initial:
Review Date:
Update Date:
Name: Jean Krier
Signature Date:
Signature:
Name:
Signature Date:
Signature:
Shampoo. Stand by to assist as needed.
Monday – Friday (5 days)
Assist Jean in maintaining her environment as she directs what is needed daily. Tasks may include:
Prepare meals as requested.
Jean is unable to drive due to braces on her left ankle and wrist/hand. Provide transportation to:
Wash, dry, fold, and put away laundry as requested. Ask daily.
Grocery or other shopping as requested.
Stand by for safety and assist if needed.
Stand by for safety and assist if needed.
Stand by for safety and assist if needed.
Monday – Friday (5 days)
Keep walkways clear. Be alert for indications of unsteadiness and provide support as needed.
Monday – Friday (5 days)
Stand by to assist with all transfers.
Stand by to assist with transfers on/off toilet.
Stand by to assist with transfers to/from bed.
Stand by for safety and assist if needed.
Stand by for safety and assist if needed.
Hands-on assistance if stairs, curbs, or other changes in elevation are encountered.