Summary Report

(PLEASE COMPLETE THIS REPORT AT THE START OF EVERY MONTH)
In correspondence to State regulations to ensure an accurate monthly summary report, we ask you, the Client, or the Caregiver, to fill out this report each and every month, preferably the start of each month. This way, only you are in charge of answering each question with your exact words, and such no biases will occur.

If you NEED a follow-up phone call to this months Summary Report, please call the office after you have submitted this Report. (1-574-288-8800)
Note: Form must be finished in its entirety once started. You can NOT save form for future edit.

    Is this form a replacement for a previously submitted form?



    Today's Date:
    Client First and Last Name:
    Enter RID Number:
    Caregivers First and Last Name:
    Phone Number:
    Address, City, Zip:


    Primary Diagnosis:

    Name of Local Agency on Area Aging:

    Allergy List:

    Diet:

    Any Restrictions:

    Corona Virus Symptoms:

    Any Falls in the last 30 days?

    Hospital and/or ER Visits:

    Admitted-in-Hospital:

    # of Days:
    Reason:
    Which Hospital:
    City:
    Were you assigned a room in the hospital?

    If so, what room number?

    Dates From (Enter date) To Date (released from hospital):

    Time released from hospital:


    Any New Skin Breakdowns:

    List:

    Any New Wounds:

    List:

    Date Last Bowel Movement:

    Client Eating Regularly:

    Daily Food Intake (since last month):

    Following Diet Plan:

    Any New Dr. Orders:

    Any New Medication Orders:

    Client Taking Meds as Prescribed:

    Enough Medications in Home (7 days worth of medications in home):

    Use any Medical Equipment:

    All Medical Equipment Working:

    If client is bed bound, are you repositioning client every 2 hours during day?

    Updated/New Phone:

    New Address:

    New Email:

    ALL Utilities ON:

    Any Emergency or Police calls to Home:

    Please describe what happened?

    Was anyone arrested?

    Smoke Detectors on each Level:

    All Working:

    Emergency Plan in Place:

    Fire Escape Plan:

    Tornado Plan in Place:

    Severe Weather Plan:

    Type of Heating:

    Type of Cooling:

    Client/Patient Signature:

    Caregiver's Printed Name:
    Caregiver's Signature:

    Electronic Signature Disclaimer


    Please ensure all information is correct before hitting Submit, as this is a Legal Document, and may be used in legal proceedings. Your signature is made with intent, and by signing your name electronically to this Summary Report, you are agreeing that your signature is the legal equivalent of your manual signature. If you want to opt out of the online Summary Report, or any other online form, please contact the office and paper forms will be sent to you.