aging.ny.gov Web viewParticipant_________________________________________________ Month...
date post
30-Jan-2018Category
Documents
view
215download
1
Embed Size (px)
Transcript of aging.ny.gov Web viewParticipant_________________________________________________ Month...
ATTACHMENT M SAMPLE SADS DAILY PARTICIPANT RECORD
Participant_________________________________________________
Month__________________________ Year_________
FUNCTIONAL ASSESSMENT/STAFF INTERVENTION
ADLs
Level of Care
Mobility
Transfers
Toileting
Continence
Eating
Self-administration of medication
Supervision and Monitoring
Participant_________________________________________________
Month__________________________ Year_________
Days of the Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
A. Physical Activities
KEY Active: A, Passive: P
Exercise/Tai Chi/Yoga
Walking/ Sports/Wii
Dance/Movement
Painting/Arts and Crafts
Cooking/Baking
Gardening
Other:
B. Intellectual/Cognitive
KEY Active: A, Passive: P
Bingo/Mathematics
Language/Memory
Reminiscence
Cards/Table Games
Computer/Tablet/Digital
Other:
C. Educational
KEY Active: A, Passive: P
Wellness Programs
Chronic Disease Self- Management
Falls Prevention
Days of the Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Educational cont.
KEY Active: A, Passive: P
Cognitive Training
Brain Health
Benefits and Services
Nutrition
Current Events
Other:
D. Spiritual
KEY Active: A, Passive: P
Nature Activities
Meditation/Relaxation
Music Therapy
Drumming Circles
Art Therapy
Dance Therapy
Writing Poetry/Stories
Performance Arts
Religious Events
Other:
E. Cultural
KEY Active: A, Passive: P
Holiday Celebrations
Remembrance Events
Arm Chair Travels
Hymns and Ethnic Music
Cultural Foods/Beverages
Videos/Theatre Groups
Time Slips
Life Review
Other
F. Socialization
KEY Active: A, Passive: P
Coffee Chat
Newspaper Time
Days of the Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Socialization cont.
Discussion Groups
Parties
Sing-A-Longs
Entertainment
Outdoors Picnics/Games
Community Outings
Volunteer Activities
Intergenerational
Other:
G. Personal Care
KEY Dry: D, Soiled/Urine: SU, Soiled/Bowel: SB
Continence Care
Toileting Time:
Toileting Time:
Toileting Time:
Toileting Time:
Self-Admin. Medications
Key Staff initials
Time:
Time:
Feeding
Key Independent: I, Set up only: S, Hands on Feeding: H
Breakfast/AM Snack
Lunch
PM Snack
Other
Key Staff initials
Bathing
Personal Hygiene
Hair Salon
Nail Care
Skin Care
Mobility/Transfer Assistance
Days of the Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
H. Psycho-Social
Key Yes: Y, No: N
Orientation
Time
Place
Person
Alert/Pleasant/Clear
Alert/Pleasant/Confused
Withdrawn/Flat Affect
Depressed/Isolates Self
Expresses Frustration
Agitated Behavior
Aggressive Behavior
Wandering
Communicates Needs
Other:
I. Nutrition
Key % of intake 100%, 75%, 50%, 25%, 0%
Breakfast
Lunch
PM Snack
Fluids
Fluids
J. Other
Key Actual time in/out, Yes: Y, No: N
Arrival time
Departure time
Caregiver transportation
Transportation Services
Caregiver contact
Staff Signatures and Initials:
July 2015
![[Date] [Participant Name Participant Address1 Date] [Participant Name Participant Address1 Participant City ST Zip] Dear Participant: RE: Request for Hardship Distribution under the](https://static.fdocuments.net/doc/165x107/5b002b357f8b9af1148c48bc/date-participant-name-participant-address1-date-participant-name-participant.jpg?t=1660018066)
