Childcare | Respite Care

Respite Caregiver Checklist

Respite care is when someone comes and gives the regular caregiver some "time off" from their duties (and is usually covered in some extent by most home health care policies). But that does not mean that the respite care caregiver has complete knowledge of the patient nor knows the best way of treating them. Here is checklist developed by Dini Alves who cared for her mother for 15 years. She suggests that the caregivers be given this form along with backup instructions for Universal Precautions, advanced directives, food preferences or any medical equipment in use. Print out and make your own revisions.

Patient _____________________ Social Security Number ________________

Birth date_________ 

Doctor______________________________ Phone ____________________

Location___________________

Hospital_______________________ Phone __________________

Medical Insurance______________________________

Home/ Health/Hospice Patient?_______ Agency Phone__________________

Nurse_______________

Diagnoses________________________________________ How Long___________

Characteristics of diagnoses affecting care

 ____________________________________________________________________

Current Symptoms _____________________________________________________

Allergies ____________________________________________________________

History of seizures? ____________________________________________________

Patient's general emotional state (shy, sense of humor, weepy, outbursts, etc)

___________________________________________________________________

_____ Generally understand instructions

_____ May not understand instructions

_____ Vision Limitations

Favorite distractions/Likes________________________________________________

Dislikes______________________________________________________________

Universal Precautions instructions can be found ________________________________

Vital Signs

____Don't need to take. ______ Take every ____ Hours. ______

Record date, time and reading on separate sheet of paper

____ Pulse _____ Blood Pressure ____ Respirations Temperature

__under tongue__ Other

 

Medications	Dose	Time to be Given	Special Instructions*

*Special Instructions

A. Give on Empty Stomach
B. Wake up patients to give Medications
C. With food/liquid (circle)
D. Give (time) before eating
E. Give on patient Request
F. Avoid ______________
G. Document when given
H. Other _____________

 

 

Appointments (doctor's office, physical therapy, beauty/barber, visit friends, ball game, etc.)
To (Name)	Location	Phone	Date	Time

Personal Care and Comfort

Personal Care needs (attach instructions to this sheet)
 

Catheter Care	Hearing aid	Shaving	Peri-Care	Mouth/Oral care
Bed Sores	Foley Bag	Dressings Changed	Hair/skin/nail care	Dentures

Moving Patient
 

Moves around unassisted

Transfers from bed to chair with assistance

Bedbound

Reposition

Requires Special lift

Special Instructions

Walking/transporting patients
 

Unassisted

Cane

Walker

Wheelchair

Physical Therapies

1. Unassisted
2. Needs Assistance
3. Range of Motion__________________________ Frequency ________________
4. Special Exercises ________________________________________

Toileting
 

Unassisted	Bedpan	Urinal	Catheter	Colostomy
Bedside Commode	Incontinent pads	other

Bathing
 

Bed bath

Shower

Tub

Needs assistance

__times per week

Equipment Needed

1. None
2. Transfer bench
3. Shower bench
4. Wheelchair

Bedroom Comfort
 

Bedtime	Wake time	Nap time(s)	Room temperature	Closed windows
Prefers room dark

Change Bed
 

Full sheet

Blanket (s)

Day___ or night___

Special bed items (sheepskin, egg crate mattress, extra pillows- attach sheet)

Food-for meals/snacks or special instructions, see attached list

 

Needs Assistance feeding	Needs to be fed	Has difficulty swallowing	Takes nothing by mouth	Tube feeding
Soft food	Record Liquid Intake

Meal times___ Breakfast____Luch_____ Dinner_______Snack

Entertainment Options/preferences
 

TV

Radio

Reading or being read to

Cards

Other

Avoid_________________________________________________________

House Rules and Instructions

1. Locking Doors
2. Don't Smoke
3. Working Stove
4. Fireplace
5. Gas shut off valve
6. Fire Extinguishers
7. Guests
8. Pet Care guidelines
9. Neighbors

Other information ______________________________________________________

____________________________________________________________________

____________________________________________________________________


Emergency Preparedness

Discuss 911 preferences________________________________________________

DNR Order or Advanced Directives can be found_____________________________

I'll return home on____________________

I will be away from ________________________to__________________________

Location_______________________________________Phone________________

Friends and Relatives you can contact in an emergency

Name/address_______________________________________________________

Phone__________________

Name/address_______________________________________________________

Phone__________________

Written by Dini Alves.  Reprinted with permission from www.efmoody.com.












 

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