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Run: Home Health Aide Plan of Care and Assignment Sheet

This Home Health Aide Plan of Care and Assignment Sheet records RN-directed aide duties, visit frequency, supervision, and escalation instructions in one pla...

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Patient and Episode Information

Patient Identifier (required)

Use the agency medical record number or other internal identifier. Do not enter a full SSN.

Patient Name (required)

Enter the patient’s full name as listed in the chart.

Start of Care Date (required)

Primary Diagnosis

Optional if needed for aide task context. Collect only if relevant to the assignment.

Attending RN Name (required)

Aide Assignment Summary

Assignment Effective Date (required)

Visit Frequency (required)

If Other, describe visit frequency

Authorized Aide Service Hours per Visit

Enter the number of hours authorized for each visit, if applicable.

Planned Duration of Aide Services (Weeks)

Assigned Aide Duties

Assigned Duties (required)

Describe Other Assigned Duties

Tasks Not Permitted for the Aide

Document any prohibited tasks or scope limitations to support safe delegation and supervision.

Special Instructions for Aide Care

Include patient-specific instructions, safety precautions, equipment use, and escalation guidance.

Supervision and RN Oversight

Supervisory Visit Frequency (required)

If Other, describe supervisory visit frequency

RN Follow-Up Required After Changes in Condition? (required)

Events the Aide Must Report Immediately (required)

If Other, describe reportable events

Consent, Attestation, and Submission

This assignment is consistent with the current plan of care. (required)

Yes No N/A

I understand this form may contain patient PII and will be handled according to agency privacy and access controls. (required)

Yes No N/A

RN Attestation (required)

The RN confirms the aide tasks, supervision expectations, and escalation instructions have been reviewed and assigned appropriately.

Attestation Date (required)

Submission Notes

Optional internal notes for the audit trail. Do not include unnecessary PII.

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Email (required)

Your name (optional)

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