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Non-medical home care Plan of Care template

A printable Plan of Care for private-pay agencies: client details and contacts, services and schedule, duties by category and weekday, medication reminders, and signatures.

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Agency name

Plan of Care

Non-medical home care services

Client

NameDate of birth
AddressPhone
RepresentativeRelationshipPhone
PhysicianPhone
AllergiesDiet
Mobility / equipmentEmergency contact

Services

Personal careHomemakerCompanionHourlyLive-in24-hour / continuous
Days and hoursStart date

Duties

CategoryDuty and instructionsEvery visit / As neededSuMoTuWeThFrSa
Bathing
Dressing
Grooming / oral care
Toileting / incontinence
Ambulation / exercise
Medication reminders
Meal preparation
Housekeeping / laundry
Errands / appointments
Companionship

Medications (reminders only, no administration)

MedicationDoseTime(s)Notes

Preferences and goals

Agreement

Client signature and date
Representative signature and date (if applicable)
Agency representative signature and date
Next review date
Plan of Care · Free template from aidebook.appAideBook fills this in from each visit

Letter size, prints in black and white. Free to use and copy for your agency.

How to fill in the Plan of Care

  1. Client and contacts. Include the representative who can sign for the client, the physician, allergies and any mobility equipment.
  2. Services and schedule. Tick personal care, homemaker or companion, the shift type, and the agreed days and hours.
  3. Duties. For each category, describe exactly what the caregiver does (“stand-by assist with shower, client washes own hair”), whether it’s every visit or as needed, and tick the days it’s due.
  4. Medications. List only what the caregiver reminds the client about. Non-medical caregivers don’t administer medication.
  5. Preferences and goals. Routines, food likes and dislikes, what the client wants to keep doing themselves.
  6. Signatures and review date. Have the client or representative and the agency sign, and set the next review.

Be specific

“Help with bathing” leaves every caregiver to guess. “Shower Tue and Fri, client sits on shower chair, caregiver washes back and feet” means the same care on every visit, and a daily log that actually proves it happened.

Pair it with a daily log

Caregivers record each visit against this plan on the caregiver daily log, using the same duty names.

Questions

Frequently asked questions

Who the client is and who to call, the services the agency will provide and on which days, specific instructions for each duty, medications the caregiver will remind the client about, preferences and goals, and signatures from the client or representative and the agency.

A home health plan of care is a clinical document ordered by a physician for skilled services like nursing or therapy. A non-medical Plan of Care covers personal care, homemaking and companionship, and caregivers only remind clients about medications rather than administering them.

Whenever the client’s needs change, and on a regular schedule your state requires. Put the next review date on the plan so it doesn’t slip.

The client, or a representative for them, and someone from the agency. Keep the signed copy in the client’s file and share the duties with the caregivers who serve them.

Keep reading

Early access for private-pay home care agencies

Turn the plan into the caregiver’s checklist.

In AideBook, each client’s Plan of Care is built from your duty catalog, signed on screen or on paper, and shows up on the caregiver’s phone at every visit.

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