Free Form 02AG044E - Oklahoma

*02AG044E-001*
OKLAHOMA DEPARTMENT OF HUMAN SERVICES

State Plan Personal Care (SPPC) Progress Notes
Agency provider use only Copy to: Client OKDHS nurse Date sent: File Date sent: Case number County

Agency RN signature

Date

Reason for visit:
Initial Assessment, Form 02HM003E, Uniform Comprehensive Assessment, Part III Routine follow-up Re-certification Change in condition Request for changes Problem or complaint Other

Follow-up visit:
Visit made for purpose of assessing client's satisfaction with care AND adequacy of goals and units allotted. Health history:

Nursing assessment: Health conditions Comment: Unchanged Improved Deteriorated

Medication concerns and changes Comment:

Yes

No

OKDHS issued 2-15-2007

02AG044E

Page 1 of 4

State Plan Personal Care (SPPC) Progress Notes New medications since initial assessment or last visit: Name Dosage Frequency Physician

02AG044E

Date filled

Physician name Client treated in Comments: emergency room or

Contact number hospital since last visit?

Date of last visit Yes No

Restriction of activities: Cane Transfer assist Walker Bedfast Wheelchair Crutches Partial weight bearing Other Yes No

Has client experienced a significant weight change in last six months? Gain or loss attributed to: Weight: Current diet: Nutritional supplements used: Name, quantity, and frequency: Comments:

Yes

No

Home-delivered meals: Agency Skin condition: Condition of skin Visible sites Cuts Bruise Location of site Comments:

Yes

No Frequency

Peripheral edema

Decubitus/lesions

Rash

Incision

Other:

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OKDHS issued 2-15-2007

02AG044E Mental status: Oriented Depressed Comments: Confused Comatose

State Plan Personal Care (SPPC) Progress Notes

Forgetful Other

Anxious

Lethargic

Functional limitations: Non-Ambulatory Amputation Hearing ADL functions: IADL functions: Comments: Ambulatory with assist Paralysis Contracture Speech Visual impairment Unchanged Unchanged Poor Poor Fair Fair Limited endurance Other Improved Improved

Safety issues: Comments:

Yes

No

Client communication: Client rating of own health: Comments: Poor Fair Good Excellent

Informal support: Primary caregiver:

Inadequate

Adequate

What do they do to assist you and how often?

Formal support: Home health Hospice Adult day services VA aide Other Indian health

What do they do to assist you and how often?

OKDHS issued 2-15-2007

Page 3 of 4

State Plan Personal Care (SPPC) Progress Notes Personal care services: Can you tell me the name of your personal care assistant (PCA)? Name: Is the PCA related to you? Relation: Your PCA works for what agency? Does your PCA arrive on time? Stay the allotted time? Comments: Yes Yes No No Yes No

02AG044E

Yes

No

When your PCA is unable to make your regular visit, does agency send someone else? Yes No Comments: Task frequency reported by client: Wed Mon Sun Thu Tue Check task designated on Care Plan Bathing Grooming Hair care Ambulation Meal preparation Laundry Housekeeping Errands/shopping Other Daily totals No change needed in hours Decrease hours = hours/week Number authorized/week Reassignment of hours Increase hours Client comments

Service Plan change needed Yes No New Form 02AG031E (AG-6), Personal Care (PC) Service Plan, required for all changes in units. Next scheduled follow-up visit is . Yes No Copy of Care Plan and Service Plan in the home:

Page 4 of 4

Sat

Fri

OKDHS issued 2-15-2007