Sample Assisted Living Sample Weekly Care Notes

Assisted Living

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Sample Weekly Care Notes Per COMAR 10.07.14.27D: D. Resident Care Notes. (1) Appropriate staff shall write care notes for each resident: (a) On admission and at least weekly; (b) With any significant changes in the resident’s condition, including when incidents occur and any follow-up action is taken; (c) When the resident is transferred from the facility to another skilled facility; (d) On return from medical appointments and when seen in home by any health care provider; (e) On return from nonroutine leaves of absence; and (f) When the resident is discharged permanently from the facility, including the location and manner of discharge. (2) Staff shall write care notes that are individualized, legible, chronological, and signed by the writer. The following are three (3) samples of forms that may be used to satisfy the weekly care note requirement. Please note that these forms are not meant to be all inclusive; if warranted, additional information may be required. In addition, these samples may not be used for the admission, transfer, or discharge notes. If your program already maintains a resident record (daily or otherwise) that meets all the requirements set forth in COMAR 10.07.14.27D, you do not need to write a duplicate weekly note (provided a note is already written for each resident at least weekly).

 

ABC Assisted Living WEEKLY CARE NOTES Resident Name_______________________________________ Date ____________ Has this resident had any medical issues or cognitive changes in the past week? Yes ____ No ____ If yes, please see nurses notes. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Has the resident had any new orders in the past week? Yes ____ No ____ If yes, please see physician’s orders. Has the resident had any changes in ADL function? Yes ____ No ____ If yes, please explain and change Service plan if needed. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Has the resident had any tests or labs done in the past week? Yes ____ No ____ If yes, see lab/x-ray section of the chart. Comments: ________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Nurses signature: _________________________________________________ Date ____________ Has this resident had any medical issues or cognitive changes in the past week? Yes ____ No ____ If yes, please see nurses notes. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Has the resident had any new orders in the past week? Yes ____ No ____ If yes, please see physician’s orders. Has the resident had any changes in ADL function? Yes ____ No ____ If yes, please explain and change Service plan if needed. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Has the resident had any tests or labs done in the past week? Yes ____ No ____ If yes, see lab/x-ray section of the chart. Comments: ________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Nurses signature: __________________________________________________ EFG Assisted Living RESIDENT WEEKLY LOG Resident Name_______________________________________ MONTH _______________YEAR_____________ Did resident go to the doctor this week? Any change in medication? Any physical or behavioral changes? Any new complaints? YES NO YES NO YES NO YES NO Comment on any yes responses, or state that resident is stable: Signature_________________________Date_______________________ Did resident go to the doctor this week? Any change in medication? Any physical or behavioral changes? Any new complaints? YES NO YES NO YES NO YES NO Comment on any yes responses, or state that resident is stable: Signature_________________________Date_______________________ Did resident go to the doctor this week? Any change in medication? Any physical or behavioral changes? Any new complaints? YES NO YES NO YES NO YES NO Comment on any yes responses, or state that resident is stable: Signature_________________________Date_______________________ Did resident go to the doctor this week? Any change in medication? Any physical or behavioral changes? Any new complaints? YES NO YES NO YES NO YES NO Comment on any yes responses, or state that resident is stable: Signature_________________________Date_______________________ XYZ Assisted Living Weekly Care Note Resident: ____________________________________ Month: _________________________________ Week: _______________________________ Changes in medication? yes no n/a Changes in food intake? yes no n/a Changes in behavior? yes no n/a Changes in mental status? yes no n/a Falls? yes no n/a Skin Issues? yes no n/a Constipation Issues? yes no n/a Insomnia problems? yes no n/a Hospitalizations/ER Visits? yes no n/a Doctor Appointments? yes no n/a Other changes to care? yes no n/a Explain any items marked yes above. Were these reported to the ALM and/or Delegating Nurse? Also document any other observations. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ _______________________________________________Signature:__________________________________ Week: _______________________________ Changes in medication? yes no n/a Changes in food intake? yes no n/a Changes in behavior? yes no n/a Changes in mental status? yes no n/a Falls? yes no n/a Skin Issues? yes no n/a Constipation Issues? yes no n/a Insomnia problems? yes no n/a Hospitalizations/ER Visits? yes no n/a Doctors Appointments? yes no n/a Other changes to care? yes no n/a Explain any items marked yes above. Were these reported to the ALM and/or Delegating Nurse? Also document any other observations. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ ___________________________________________________Signature:_____________________________

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