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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

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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

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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

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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

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2

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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