Care Plan Phase 5 — Run Your Practice

How to use this document

1Fill out one care plan per client at or shortly after the meet-and-greet.
2Review it with the family contact — they should confirm the routine, ADL levels, and emergency info.
3Print two copies: one for your records, one to keep in the client's home.
4Update it any time the client's condition, routine, or care needs change.
Phone
Email

Client Care Plan

Date Created:
Last Updated:

1. Client Information

Client full name

Date of birth

Home address

Preferred language

Primary family contact & relationship

Family contact phone

Primary physician

Physician phone

2. Medical & Health Background

Primary diagnosis / conditions

Known allergies

Current medications (reminders only — no administration)

Mobility status

Cognitive status

Fall risk

3. Activities of Daily Living (ADL Assessment)

Activity Independent Needs Assistance Full Assistance Notes

4. Daily Routine

Morning

Afternoon

Evening

5. Dietary & Nutrition

Diet type / restrictions

Texture modification

Fluid restrictions

Food preferences / dislikes

6. Behavioral & Cognitive Notes

Communication style & preferences

Known triggers or difficult behaviors

What helps / de-escalation strategies

7. Care Goals

What do we want to achieve or maintain for this client this quarter?

1
2
3

8. Emergency Information

Emergency contact (if different from family contact)

Emergency contact phone

Preferred hospital

DNR on file?

Special notes for emergency responders

9. Review & Signatures

This care plan has been reviewed and agreed upon by both the caregiver and the client's authorized family member.

Caregiver Signature

Date

Family / Authorized Contact Signature

Printed name

Relationship to client

Date

This care plan is a working document — update it as the client's needs change.
Keep one copy in your records and one copy in the client's home.