* = Required Information
Health Needs Change Notice
A Helping Hand Senior Care Services must report any change in a person’s physical and mental health needs when assigned in the Coordinated Service and Support Plan or Coordinated Service and Support Plan Addendum. This completed form should be printed, signed and dated, and placed in the person’s file.
Date a change in physical and/or mental health needs was discovered
Date of Notification to
The Health Needs Change includes
Addition of a psychotropic
Name of new medication
Increase in dosage of a current psychotropic medication
Note: If the person or the person’s legal representative refuses to authorize the administration of a psychotropic medication, the refusal must be reported to the prescriber. After reporting to the prescriber, A Helping Hand Senior Care Services must follow any directives given by the prescriber.
Other change in the person’s physical and/or mental health needs
Describe the change in detail
Reminder: The Health Needs section of the person’s report form must be updated with this information.
Date of the report