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 the 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. But do use it- it can save a lot of time, questions and anxiety

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, sudden outbursts, etc)______________________________________________________________________

_____ Generally understand instructions

____ May not understand instructions

_____ Vision Limitations

Favorite distractions/Likes______________________________________________________


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

1. __________________________________________________________________________

2. __________________________________________________________________________

3. __________________________________________________________________________

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 _____________

Medical Equipment When Needs Assistance Need to Know

1. __________________________________________________________________________

2. __________________________________________________________________________

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

1. __________________________________________________________________________

2. __________________________________________________________________________


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 life

Special Instructions

Walking/transporting patients
Unassisted Cane Walker Wheelchair

Physical Therapies

1. Unassisted

2. Needs Assistance

3. Range of Motion__________________________ Frequency ___________________

4. Special Exercises ________________________________________

Unassisted Bedpan Urinal Catheter Colostomy
Bedside Commode Incontinent pads other

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
Pull sheet Blankets(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 foods Record Liquid Intake

Meal times___ Breakfast____Luch_____ Dinner_______Snack

Entertainment Options/preferences
TV Radio Reading or being read to cards Other



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____________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________


Discuss 911 preferences_____________________________________________________

DNR Order or Advanced Directives can be found______________________________

I'll return home on____________________

I will be away from ________________________to________________________


Friends and Relatives you can contact in an emergency

Name/address_____________________________________________ Phone____________

Name/address_____________________________________________ Phone____________

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