resident service plan form
TRANSCRIPT
Veritas Resident Service Plan Form (RSP)
Page 1 of 8 RSP Form Revised 011420
Community: ____________________________________ Apt#: ____________ Resident Name: ___________________________________________ Code Status: _________ Primary Contact/Responsible Party: ___________________________________________________ Telephone: _________________ Primary Physician(s): _______________________________________________________________ Telephone: _________________ 1. MONITORING AND ASSESSMENT — MEDICAL CONDITIONS (INCLUDING RESPIRATORY)
Date Description of Needs Services to be Provided When How Often By Whom
2. MONITORING AND ASSESSMENT — COGNITIVE IMPAIRMENTS, COMMUNICATION IMPAIRMENTS, PSYCHIATRIC ILLNESSES AND BEHAVIORS
Date Description of Needs Services to be Provided When How Often By Whom
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Veritas Resident Service Plan Form (RSP)
Page 2 of 8 RSP Form Revised 011420
3. CARE AND SERVICE — RISK FACTOR MANAGEMENT (EXAMPLE: FALLS, SKIN BREAKDOWN, WEIGHT LOSS, DEHYDRATION, COMBATIVENESS, WANDERING)
Date Description of Needs Services to be Provided When How Often By Whom
4. CARE AND SERVICE — MEDICATION MANAGEMENT (INCLUDING MEDICATED DROPS AND SPRAYS)
Date Description of Needs Services to be Provided When How Often By Whom
Resident self-administers medication independently
Evaluate the resident’s ability to safely self-administer medications.
Authorized Nursing Staff
Resident is unable to self-administer medication
1) Medication administration program. Medications will be administered as prescribed.
As scheduled on the MAR
Authorized Nursing Staff
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Veritas Resident Service Plan Form (RSP)
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5. CARE AND SERVICE — ASSISTANCE WITH ADLS (BATHING, TOILETING, MOBILITY, TRANSFERS, ORAL CARE AND GROOMING, DRESSING, FEEDING) Date ADL Needs I S
B 1 P
2 P
Services to be Provided When How Often By Whom
Eating Assistance Type: ______________ � Special diet: ______ � Cut up food � Mechanical soft � Pureed � Escort to meals
Mobility Assistance � Cane � Walker � W/C � Escort to activities � Stairs � Bed
Transfer Assistance
Toileting Assistance
� Incontinence bladder
� Incontinence bowel
� Toileting schedule
Bathing Assistance Showering: � Yes � No
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Veritas Resident Service Plan Form (RSP)
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5. CARE AND SERVICE (CONTINUED) – ASSISTANCE WITH ADLS (BATHING, TOILETING, MOBILITY, TRANSFERS, ORAL CARE AND GROOMING, DRESSING, FEEDING) Date ADL Needs I
1 P
2 P
Services to be Provided When How Often By Whom
Tub Bath: � Yes � No
Oral Care & Grooming � Dentures � Upper � Lower � Partial
Dressing Assistance
Date ADL Needs I
1 P
Services to be Provided When How Often By Whom
Meal Preparation Housekeeping Shopping Managing Finances Transportation Telephone Use 6. CARE AND SERVICE — PERFORMING TREATMENTS FOR PHYSICAL /MEDICAL CONDITIONS
Date Description of Needs Services to be Provided When How Often By Whom
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S B
S B
Veritas Resident Service Plan Form (RSP)
Page 5 of 8 RSP Form Revised 011420
7. CARE AND SERVICE — MANAGEMENT OF PROBLEMATIC BEHAVIOR
Date Description of Needs Services to be Provided When How Often By Whom
8. OTHER SERVICES
Date Description of Needs Services to be Provided When How Often By Whom
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Veritas Resident Service Plan Form (RSP)
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9. PASTORAL CARE – RELIGIOUS AFFILIATION, CLERGY, SUPPORT GROUPS, OTHER SERVICES
Date Description of Needs Services to be Provided When How Often By Whom
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Veritas Resident Service Plan Form (RSP)
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10. ACTIVITIES SERVICES Date Description of Needs Services to be Provided When How Often By Whom
Activity Pursuits Initial Activity Assessment On admission
Activity Director
Opportunities for social interaction Daily/ Evenings
Activity Staff
Provide in-room activities supplies Daily/ Evenings
Activity Staff
Provide 1:1 visits As needed Activity Staff
Provide transportation for community reintegration As needed Transport. Coordinator
11. DIETARY SERVICES
Date Description of Needs Services to be Provided When How Often By Whom
Diet and between meal snacks per physician order
Diabetic Program
Hydration Program
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Veritas Resident Service Plan Form (RSP)
Page 8 of 8 RSP Form Revised 011420
12. NUTRITION SERVICES Date Description of Needs Services to be Provided When How Often By Whom
Review of Nutritional Assessment information Weights per Physician Order
On Admission
Dietician
_______________________________________ ______________________________________
Date
_______________________________________ ______________________________________ Executive Director (ED) or Designee
Date
Service Plan Review/Revision
________________________________ ________________________________ _________________ Name
Signature
Date
________________________________ ________________________________ _________________ Name
Signature
Date
________________________________ ________________________________ _________________ Name
Signature
Date
________________________________ ________________________________ _________________ Name
Signature
Date
1st 2nd 3rd_______________________________________ ______________________________________ Resident Care Director (RCD) or Designee Date Resident / Responsible Party