SDR005.2.1 Personal Profile Template.doc … · Web viewSERVICE DELIVERY...

SDR005.2.1 Personal Profile Template.doc

PersonalProfileInformation

for

LAST UPDATED: 2014

Document Control Log

Page Number

Date Updated

Signature

Profile Sign off Page for Staff

Name

Date

Signature

SDR PERSONAL PROFILE INDEX

1. Personal Information5

2.RED ALERT - All staff must be aware of this information6

3.Key Contact List7

4.Health & Wellness9

Reference Numbers:9

General Practitioner:9

Dentist:9

Pharmacy9

Specialist10

Immunisations:11

Vision:11

Hearing:11

Epilepsy:12

Diabetes:12

Bowel Management:13

Meal Management:13

Relevant Medical Information:13

Medication:14

5.Communication and Behaviour15

General Information Regarding Communication16

Behaviour:16

6.Daily Living Skills18

Social / Recreational Activities20

Transport21

Meals22

8.Support Plans26

9.Monitoring & Recording Charts27

10.Legal & Ethical28

Profile Sign-Off:29

Personal Information

Name:

Preferred Name:

Date of Birth:

Address:

Contact Details:

Home:

Mobile:

Work:

School:

Are there any cultural or religious issues to be aware of?

YES

|_|

NO

|_|

Aboriginal |_|

Torres Strait Islander |_|

N/A |_|

Primary Carers Details

Name:

DOB:

Relationship:

Address:

Contact Details:

Home:

Mobile:

Work:

Other:

Person Responsible

Name:

As Above

Relationship:

Address:

Contact Details:

Home:

Mobile:

Work:

Other:

Emergency Contact Person (if primary carers not contactable)

Name:

Relationship:

Address:

Contact Details:

Home:

Mobile:

Work:

Other:

Advocate Details if applicable

Name:

Organisation :

Contact Details: Work:

Mobile:

Local Area Coordinator Gateway Contact Person

Name:

Contact Details: Work:

Mobile:

RED ALERT - All staff must be aware of this informationKnown Allergies / Sensitivities (eg pollens, stings, sunscreen, food, medications etc)

Any Red Alert should come with an Action Support Plan written by the appropriate professional and signed by the Doctor. e g Anaphylaxis Plan for nut allergy

Food

YES

|_|

NO

|_|

Reaction

Medication

YES

|_|

NO

|_|

Reaction

Other

YES

|_|

NO

|_|

Reaction

Other

YES

|_|

NO

|_|

Reaction

Do you give consent for sunscreen to be applied to the person?

YES

|_|

NO

|_|

Office Use - Action Plan Required?

Yes

No

N/A

Alerts cover a range of issues: e.g. Behaviour, food, diet, epilepsy, asthma, other medical.

Does the person require a secure environment?

If yes please give details

YES

|_|

NO

|_|

Profile Last Reviewed:

Confidential STAR ProfilePage 6PP Version 2013

Key Contact List

Family members, Next of Kin, Service Provider, emergency contact, advocate. Add new names and put a line through out-of date names as necessary.

Client Name:

Date

Name

Role / Relationship

Address

Phone

Fax

ConfidentialPage 7SDR Version 2013

School / Community Access Service Provider

Day

Service Provider

& Address

Mode of Transport to & from Service Provider

What does he/she usually take?

Monday

eg Parkside

eg Taxi/School bus

To

eg /Lunch/Money/Equipment/

Clothes/Sanitary items

From

Tuesday

eg Taxi/School bus

To

From

Wednesday

eg Taxi/School bus

To

From

Thursday

eg Taxi/School bus

To

From

Friday

eg Taxi/School bus

To

From

Who (authorised person/s, please name all) will drop off/collect the person from Respite?

Drop off

Name

Collect

Name

Health & WellnessReference Numbers & Expiry dates:

Medicare No:

expiry / /

Health Care Card:

expiry / /

Private Health Insurance No:

expiry / /

& Level of Cover:

Companion Card No:

expiry / /

Other:

expiry / /

General Practitioner:

Name:

Address:

Phone:

FAX:

Dentist:

Name:

Address:

Phone:

FAX:

Pharmacy

Name:

Address:

Phone:

FAX:

Specialist

Service Provided:

Name:

Address:

Phone:

FAX:

Other

Service Provided:

Name:

Address:

Phone:

FAX:

Diagnosis / Syndrome / Disorder

eg Intellectual Disability, Autism, Mental Health,

Immunisations:

Date of most recent Tetanus immunisation:

Please list any additional immunisations such as Seasonal Flu Vax,

Pneumococcal, Meningococcal, HiNi

Immunisation details

Date

Vision:

Does the person have any problem with vision?

YES

|_|

NO

|_|

Does the person wear glasses?

YES

|_|

NO

|_|

When is the person to wear their glasses?

Hearing:

Does the person have any problem with hearing?

YES

|_|

NO

|_|

Does the person have grommets?

YES

|_|

NO

|_|

Does the person have hearing aid(s)?

YES

|_|

NO

|_|

Please specify which ear if only one hearing aid

Left

|_|

Right

|_|

Please describe assistance required from staff

Epilepsy:

Does the person have Epilepsy?

YES

|_|

NO

|_|

Type of seizure?

How long since last seizure?

Usual length of seizure?

Please describe usual seizure:

Any known triggers to a seizure e.g. constipation, noise:

YES

|_|

NO

|_|

Who needs to be notified about the seizure and if so when? Immediately, or at the end of the day / stay?

Office Use - Epilepsy Plan Required?

Yes

No

N/A

Diabetes:

Please note Families / Carers are responsible for arranging Community Nursing (and appropriate Medication Chart) and payment for invasive procedures such as injections whilst staying at Respite.

Does the person have Diabetes?

Type of Diabetes

Diet Controlled / Medication please describe

YES

|_|

NO

|_|

Office Use - Diabetes Plan Required?

Yes

No

N/A

Bowel Management:

Does the person have a Bowel Management Plan?

YES

|_|

NO

|_|

Office Use Bowel Mgt Plan Required?

Yes

No

N/A

Meal Management:

Does the person have a Meal Management Plan?

YES

|_|

NO

|_|

Office Use Meal Mgt Plan Required?

Yes

No

N/A

Relevant Medical Information:e.g. Dates information of operations / previous significant illness (medical history )

Ongoing or Reoccurring Health Problems:

Any serious ongoing or reoccurring health problems?

YES

|_|

NO

|_|

Are there any activities that may aggravate this problem?

YES

|_|

NO

|_|

Medication:

Does the person require Medication whilst at Respite?

YES

|_|

NO

|_|

If so what is the medication prescribed for?

eg Epilepsy, Diabetes

If medication is administered how is it administered?Webster Pack YES |_|NO |_|Self AdministeredYES |_|NO |_|

Peg FedYES |_|NO |_|InjectionYES |_|NO |_|

Topical ApplicationYES |_|NO |_|LiquidYES |_|NO |_|

InhalerYES |_|NO |_|SpacerYES |_|NO |_|

Are there any side effects to the medication that staff should be aware of:

Does the person have any trouble taking medications?

YES

|_|

NO

|_|

Are there strategies in place at home that can be used at Respite to ensure medication is taken eg with yoghurt, fluids etc.

YES

|_|

NO

|_|

As the person responsible for

I authorise STAR staff to administer medications as stated on my behalf.

Signature of Parents / Carers

Please note

Medication Chart / s and Medication Summary Sheet are to be completed by the Doctor Medication Charts are valid for 6 months.

Medication is to be in the original container or Webster pack.

Medication is to be clearly labelled by the pharmacist.

Over the counter medication such as vitamin supplements, cough mixture or paracetamol are to be included on a medication Chart and PRN Instruction Form.

Communication and Behaviour

Ability to Understand

Yes

No

Sometimes

Comments

Understands most things that are said.

|_|

|_|

|_|

Understands simple sentences eg. Go and get your shoes.

|_|

|_|

|_|

Understands better when gestures are used as well as speech.

|_|

|_|

|_|

Responds to their name.

|_|

|_|

|_|

Looks at a person who talks to them.

|_|

|_|

|_|

Calms down when someone talks

to them.

|_|

|_|

|_|

Understands sign language.

|_|

|_|

|_|

Understands gestures.

|_|

|_|

|_|

Understands COMPIC or drawings.

|_|

|_|

|_|

Ability to Talk

Yes

No

Sometimes

Comments

Speaks clearly in sentences.

|_|

|_|

|_|

Says some short phrases.

|_|

|_|

|_|

Only speaks in single words.

|_|

|_|

|_|

Is difficult to understand.

|_|

|_|

|_|

Vocalises in a clear attempt to talk.

|_|

|_|

|_|

Uses gestures, eg pointing, waving, pretending to eat.

|_|

|_|

|_|

Gestures are easy to understand.

|_|

|_|

|_|

Uses formal sign language.

|_|

|_|

|_|

Auslan |_| Makaton |_| Others |_|

Uses pictures or symbols.

|_|

|_|

|_|

Speaks another language at home.

|_|

|_|

|_|

General Information Regarding CommunicationHow does the person get the attention of others?

How does the person show that they are happy or sad?

Does the person use communication aides to communicate?Please specify eg Communication book

Thinking Skills / Ability

Yes

No

Comments

Does the person require assistance with choices or decision making?

|_|

|_|

Does the person find it difficult to stay on task?

|_|

|_|

Does the person find it difficult to shift attention off one idea, or repeat words over and over?

|_|

|_|

Does the person have problems with Immediate memory, short term memory, long term memory?

|_|

|_|

Does the person take time to process instructions?

|_|

|_|

Does the person display emotions out of proportion with situations or shift from one mood to another?

|_|

|_|

Is the person able to complete tasks step by step or are they able to complete steps in order?

|_|

|_|

Behaviour:

Are there any behaviours displayed that will place the person or others at risk?

YES

|_|

NO

|_|

Are there any known triggers or warnings for this behaviour?

YES

|_|

NO

|_|

Office Use Current Behaviour

Support plan received?

Yes

No

N/A

Is there a formal Behaviour Management Plan with identified strategies?

YES

|_|

NO

|_|

If NO are there any strategies that are successful?

General Information Regarding Safety

Without staff supervision

Is the person likely to wander or abscond?

YES

|_|

NO

|_|

Does the person have road safety awareness?

YES

|_|

NO

|_|

Is the person unable to find their way back to the premises?

YES

|_|

NO

|_|

Is the person vulnerable to abuse or exploitation by others?

YES

|_|

NO

|_|

Please describe any relevant information

Does the person have any known fears or phobias?

YES

|_|

NO

|_|

Does the person mix well with others?

YES

|_|

NO

|_|

Daily Living SkillsSleeping

What time does the person usually go to bed?

Week days

Weekends

What time does the person usually get up?

Week days

Weekends

What does the person usually wear to bed?

Does the person sleep in a regular bed?

YES

|_|

NO

|_|

Please describe sleep position:

Does the person require assistance during the night?

YES

|_|

NO

|_|

Is the person able to share a room?

If no please explain why

YES

|_|

NO

|_|

Does the person have a routine that helps them settle at night?

YES

|_|

NO

|_|

Is the person incontinent at night?

YES

|_|

NO

|_|

Does daytime sleeping effect night time sleep patterns?

YES

|_|

NO

|_|

Dressing

Does the person require assistance to choose appropriate clothing?

YES

|_|

NO

|_|

Does the person require assistance to dress?

YES

|_|

NO

|_|

Toileting

Does the person have a toilet program?

If yes please attach program.

YES

|_|

NO

|_|

Is the person continent?

YES

|_|

NO

|_|

Does the person require assistance with toileting?

YES

|_|

NO

|_|

Does the person suffer from constipation / diarrhoea?

YES

|_|

NO

|_|

Does the person use continence aids?

Please give details of continence aids used and a guide for usual change times.

YES

|_|

NO

|_|

:

Does the person have a bowel management regime?

YES

|_|

NO

|_|

Is a toilet record required?

YES

|_|

NO

|_|

Office Use - Bowel Mgt Plan required?

Yes

No

N/A

Bathing and Hygiene

Is a bath or shower preferred?

Does the person require assistance with personal care, washing hair and bathing?

YES

|_|

NO

|_|

If no is the person able to be left unattended to bathe independently?

YES

|_|

NO

|_|

Are bathing aids used?

YES

|_|

NO

|_|

Please describe the bathing routine (morning / night etc):

Is assistance required with shaving?

YES

|_|

NO

|_|

Please also note how often:

Is assistance required with teeth cleaning?

YES

|_|

NO

|_|

Please also note usual times:

Are earplugs required when bathing and or showering?

YES

|_|

NO

|_|

Is assistance required for hand washing?

YES

|_|

NO

|_|

Are there any allergies (respiratory or skin) to personal products?

YES

|_|

NO

|_|

Powders, lotions, deodorants soaps etc:

Money

Does the person handle money?

YES

|_|

NO

|_|

Does the person require assistance with handling money?

YES

|_|

NO

|_|

Social / Recreational ActivitiesLikes:

Dislikes:

Must do:

Cant do:

Do you consent for the organisation to take the person off-site on excursions (e.g. movies)

YES

|_|

NO

|_|

Do you consent for the organisation to take the person swimming / water activities?

Pool

YES

|_|

NO

|_|

Beach

YES

|_|

NO

|_|

Are there any special considerations when accessing the community? (if yes please note below.)

YES

|_|

NO

|_|

Transport

Family / Carers are responsible for arranging transport and its payment to and from Respite. Family / Carers are also responsible for arranging any other transport from Respite to venues eg: school, day support, etc during a clients booking at Respite.

Does the person:

Sit in an ordinary seat in the bus / car?

YES

|_|

NO

|_|

Independently climb in / out of bus / car?

YES

|_|

NO

|_|

Does the person;

Require a car / booster seat in the bus / car?

YES

|_|

NO

|_|

Require a harness?

YES

|_|

NO

|_|

Sit in a wheelchair in the bus / car?

YES

|_|

NO

|_|

Catch public transport independently?

YES

|_|

NO

|_|

Does the person have taxi concession vouchers?

YES

|_|

NO

|_|

Drinking

What does the person drink from:

(Please supply named personal drinking aid if required)

Does the person require assistance?

YES

|_|

NO

|_|

Details:

Likes:

Dislikes:

Must have:

Must never have and why:

MealsPlease note likes and dislikes for meals

Breakfast:

Morning Tea:

Lunch:

Afternoon Tea:

Dinner:

LikesDislikes

Does the person require assistance?

YES

|_|

NO

|_|

Details:

Does the person require specific aids for meal time assistance?

Please give details and supply and name aids.

Favourite Foods:

Food Dislikes:

Does the person require meals at specific times?

If so please note times below.

Mobility & EquipmentMobility:

Walks:

On own?

YES

|_|

NO

|_|

With assistance?

YES

|_|

NO

|_|

Crawls?

YES

|_|

NO

|_|

If assistance is required please provide details?

Uses Wheelchair:

On own?

YES

|_|

NO

|_|

With assistance?

YES

|_|

NO

|_|

Indoors?

YES

|_|

NO

|_|

Outdoors?

YES

|_|

NO

|_|

Sits on chair:

Unassisted?

YES

|_|

NO

|_|

With assistance?

YES

|_|

NO

|_|


Sits on floor:

Unassisted?

YES

|_|

NO

|_|

With assistance?

YES

|_|

NO

|_|


Does the person have a Manual Handling Plan?

YES

|_|

NO

|_|

Office Use Manual Handling

Plan required?

Yes

No

N/A

S:\2. SERVICE DELIVERY RES\Administration\Forms\Client\PP Updated Nov 2013.docx


Equipment:EquipmentMaintenance RequiredName of serviceContact Number

Please state any special needs with the care or maintenance of communication aids

Recharging

YES

|_|

NO

|_|

details

Transport

YES

|_|

NO

|_|

details

Use of aid

YES

|_|

NO

|_|

details


Support Plans

Please list any attachments (e.g. Health / Behaviour / Support Plans):

Monitoring & Recording Charts

Does the person require monitoring and recording charts to be completed?

(eg food, fluid, bowel, urine, seizure):

YES

|_|

NO

|_|

If YES please specify below:

Legal & Ethical

Are there any Family Court Orders or access arrangements that employees should be aware of?

YES

|_|

NO

|_|

If YES please provide a copy of the written documentation.

Attached:

|_|

Are there any Medical Authority orders in place that employees should be aware of?

YES

|_|

NO

|_|


Attached:

|_|

Are there any Guardianship and Administration orders that employees should be aware of?

YES

|_|

NO

|_|


Attached:

|_|

Has the Client Image Consent Form been signed?

YES

|_|

NO

|_|


Attached:

|_|

Are there any other Legal or Ethical Issues that are not listed above that employees should be aware of?

YES

|_|

NO

|_|

If YES please be specific and provide a copy of any written documentation.

Attached:

|_|

Profile Sign-Off:

This profile will be updated bi-annually, however, if any situation changes dramatically during the year please inform employees as soon as possible so that it may be recorded.

Please name the people who have had input into this profile:

By signing this you are acknowledging that the information contained within this document is true and correct and are consenting to the use of this information for the development of programs, activities and service provision, including emergency medical treatment.

Name:

Relationship:

Signature:

Date:

Name:

Relationship:

Signature:

Date:

Name:

Relationship:

Signature:

Date:

This profile will be of great assistance to staff in supporting this service user at Respite. Thank you for your input and time into completing this profile.


SDR005.2.1 Personal Profile Template.doc … · Web viewSERVICE DELIVERY...

Documents

Transcript of SDR005.2.1 Personal Profile Template.doc … · Web viewSERVICE DELIVERY...