Unable to safely occupy own time: less than one hour less than three hours less than 8 hours Part B. Health & ADL/IADL Support Needs INCONTINENCE EATING MOBILITY bladder swallowing issues uses wheelchair bowel special diet uses walker requires direct support for requires direct support for uses cane toileting eating requires direct support for requires cueing/monitoring for requires cueing/monitoring moving toileting requires cueing/monitoring for moving BATHING AND DRESSING SLEEP List any Specialized Nursing Care Issues requires direct support for awake at night bathing sleeps less than 6 consecutive requires cueing/monitoring for hours at night bathing CPAP requires direct support for BIPAP dressing requires cueing/monitoring for dressing IADLs (check item if help needed with this task) household chores money management laundry shopping cooking 9. Medications Name of Medication Reason Prescribed Dosing Amount and Directions
Unable to safely occupy own time: less than one hour less than three hours less than 8 hours Part B. Health & ADL/IADL Support Needs INCONTINENCE bladder bowel requires direct support for toileting requires cueing/monitoring for toileting EATING swallowing issues special diet requires direct support for eating requires cueing/monitoring MOBILITY uses wheelchair uses walker uses cane requires direct support for moving requires cueing/monitoring for moving BATHING AND DRESSING requires direct support for bathing requires cueing/monitoring for bathing requires direct support for dressing requires cueing/monitoring for dressing SLEEP awake at night sleeps less than 6 consecutive hours at night CPAP BIPAP List any Specialized Nursing Care Issues IADLs (check item if help needed with this task) household chores money management laundry shopping cooking 9. Medications Name of Medication Reason Prescribed Dosing Amount and Directions