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South Carolina Office (843) 972-3939
Greensboro Office (336) 914-1352
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Apex Mind Health Solutions
About
Services
Personal Care Services
Companion Care Services
Respite Care Services
24-Hour Care Services
Homemaking Services
Skilled Nursing Care
Memory Care
Veterans Care
CAP/DA – Adult Medicaid Waiver
CAP/C – Children’s Medicaid Waiver
Our Office Locations
Raleigh Office
South Carolina Office
Greensboro Office
Blogs
Careers
Pre-Hire
Post-Hire
Assessment Center
CNA School
Service Areas
Resources
Contact
Apex Mind Health Solutions
Care Plan
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Client Information
Personal Information
First Name
Last Name
Goes By
Birth Date
MM slash DD slash YYYY
Gender
Male
Female
Contact Information
Line 1
Line 2
Address
City
State
Zip Code
Home Phone
Mobile Phone
Care Instructions
Level of Care
Active
Total
Standby
Advance Directive
Yes
No
Advance Directive Notes
DNR
Yes
No
DNR Notes
Schedule Information
Start Date
MM slash DD slash YYYY
Schedule Comments
Responsible Parties
Responsible Party #1
Personal Information
Name
Relationship
Birth Date
MM slash DD slash YYYY
Address
Line 1
Line 2
Address
City
State
Zip Code
Contact Information
Email
Phone
Home
Mobile
Phone
Phone
Home
Mobile
Phone
Authorizations
Medical Decisions
Yes
No
HIPAA Disclosure Authorization
Yes
No
Responsible Party #2
Personal Information
Name
Relationship
Birth Date
MM slash DD slash YYYY
Address
Line 1
Line 2
Address
City
State
Zip Code
Contact Information
Email
Phone
Home
Mobile
Phone
Phone
Home
Mobile
Phone
Authorizations
Medical Decisions
Yes
No
HIPAA Disclosure Authorization
Yes
No
Responsible Party #3
Personal Information
Name
Relationship
Birth Date
MM slash DD slash YYYY
Address
Line 1
Line 2
Address
City
State
Zip Code
Contact Information
Email
Phone
Home
Mobile
Phone
Phone
Home
Mobile
Phone
Authorizations
Medical Decisions
Yes
No
HIPAA Disclosure Authorization
Yes
No
Health Care Providers
Preferred Care Providers
Preferred Hospital
Preferred Home Health Agency
Preferred Hospice Agency
Other Provider
Insurance
Long Term Care Insurance
Yes
No
Contact
Phone
Fax
Insurance Policy Number
Assessment Criteria
General Assessment
Height (ft)
Height (in)
Weight
Client alert and oriented?
Yes
No
Home environment safe and secure?
Yes
No
Client has adequate nutrition?
Yes
No
Access to proper nutrition?
Yes
No
Access to proper medical care?
Yes
No
Signs of abuse?
Yes
No
Reported abuse?
Yes
No
Medical History
Vision Issues
Yes
No
Speaking Issues
Yes
No
Breathing Issues
Yes
No
Heart Issues
Yes
No
Blood Pressure Issues
Yes
No
Circulation Issues
Yes
No
Bed Bound
Yes
No
Paralysis
Yes
No
Cancer
Yes
No
Arthritis
Yes
No
Diabetes
Yes
No
Dementia
Yes
No
Seizures
Yes
No
Hearing Loss
Yes
No
Tremors
Yes
No
Stroke
Yes
No
Alzheimer's
Yes
No
Wounds
Yes
No
Recent Surgery
Yes
No
Incontinence
Yes
No
Chronic Pain
Yes
No
Allergies
Yes
No
Fall Risk/Imbalance
Yes
No
Parkinson's
Yes
No
Supportive Devices
Dentures
Yes
No
Hospital Bed
Yes
No
Glasses
Yes
No
Ramp
Yes
No
Hearing Aid
Yes
No
Transfer Board
Yes
No
Mobility Cart
Yes
No
Cane
Yes
No
Raised Toilet Seat
Yes
No
Raised Furniture
Yes
No
Bed Rails
Yes
No
Hand-held Shower
Yes
No
Wheelchair
Yes
No
Lift Chair
Yes
No
Bedside Commode
Yes
No
Oxygen
Yes
No
ERS
Yes
No
Shower Chair
Yes
No
Grab Bars in Bathroom
Yes
No
Walker
Yes
No
Adult Diapers
Yes
No
Mechanical Lift
Yes
No
Baby Monitor
Yes
No
Other
Yes
No
Services
Meal Preparation
Yes
No
Medication Reminders
Yes
No
Light Housekeeping
Yes
No
Companionship
Yes
No
Laundry
Yes
No
Make Bed
Yes
No
Bathing
Yes
No
Hygiene Assistance
Yes
No
Transfer
Yes
No
Provider Car
Yes
No
Appointments / Errands
Yes
No
Client Car
Yes
No
Individualized Service Plan
Client Schedule
SUN
MON
TUE
WED
THU
FRI
SAT
ADLs
Ambulation
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Ambulation
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Apply Lotion
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Apply Lotion
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Assist with Urinal
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Assist with Urinal
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Assist Eating
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Assist Eating
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Assist Shaving
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Assist Shaving
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Assist to Commode
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Assist to Commode
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Assist with exercise
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Assist with exercise
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Assist with walking
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Assist with walking
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Bathing/Tub, shower or partial
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Bathing/Tub, shower or partial
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Bathroom Cleanup
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Bathroom Cleanup
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Change Bed Linens
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Change Bed Linens
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Change the Sheets
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Change the Sheets
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Clean living areas
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Clean living areas
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Client Dr. Appointment
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Client Dr. Appointment
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Client Errands
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Client Errands
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Client Transportation
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Client Transportation
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Companionship
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Companionship
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Cooking
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Cooking
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Cutting Food
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Cutting Food
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Dishwashing
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Dishwashing
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Dispose of garbage
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Dispose of garbage
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Exercise reminders
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Exercise reminders
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Fall Risk
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Fall Risk
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Feeding
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Feeding
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Grooming
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Grooming
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Hair Care
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Hair Care
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Homemaker
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Homemaker
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Hoyer Lift Assist
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Hoyer Lift Assist
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Hygiene Assistance
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Hygiene Assistance
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Incontinence Care
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Incontinence Care
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Kitchen Cleanup
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Kitchen Cleanup
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Laundry
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Laundry
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Light Housekeeping
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Light Housekeeping
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Make Bed
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Make Bed
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Meal Preparation
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Meal Preparation
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Medication Reminders
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Medication Reminders
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Positioning
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Positioning
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Range of Motion Exercises
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Range of Motion Exercises
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Shampoo Hair
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Shampoo Hair
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Taking client to appointment
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Taking client to appointment
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Toileting Assistance
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Toileting Assistance
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Transferring
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Transferring
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Turn Client
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Turn Client
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Well Being Observation
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Well Being Observation
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Always
As Needed
Specific Times
Never
Attributes
Smoker
Yes
No
Does client smoke
Cat Friendly
Yes
No
Have cat
Transportation
Yes
No
Need transportation
Client Signature
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Raleigh · Greensboro · Beaufort | A-1 Omega Healthcare Services Inc
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