aging.ny.gov Web viewParticipant_________________________________________________ Month...
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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 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: July 2015
Transcript of aging.ny.gov Web viewParticipant_________________________________________________ Month...
ATTACHMENT M SAMPLE SADS DAILY PARTICIPANT RECORD
Participant_________________________________________________ Month__________________________ Year_________
FUNCTIONAL ASSESSMENT/STAFF INTERVENTIONADLs Level of Care
Mobility Transfers Toileting Continence Eating Self-administration of medication Supervision and Monitoring
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
July 2015
Participant_________________________________________________ Month__________________________ Year_________
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
Participant_________________________________________________ Month__________________________ Year_________
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
Participant_________________________________________________ Month__________________________ Year_________
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
Participant_________________________________________________ Month__________________________ Year_________
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
Participant_________________________________________________ Month__________________________ Year_________
Communicates Needs
Other:
I. Nutrition Key % of intake 100%, 75%, 50%, 25%, 0%
BreakfastLunch
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:
