* = Required Information
Primary DSP Checklist
Individual
*
Date
*
Location
*
Staff Name
*
Review of Outcomes (from individual’s book)
Outcome #1
Completed prior week:
Yes
No
Outcome #2
Completed prior week:
Yes
No
Outcome #3
Completed prior week:
Yes
No
Outcome #4
Completed prior week:
Yes
No
Weight:
* Weight must also be recorded in the Health Progress Notes
Room Check - Ensure room is neat and clean, no inappropriate or unsafe items
Staff
Resident Initials
Review schedule of activities for the week
Staff
Resident Initials
Check personal hygiene items, clothing, etc. to be sure they have an adequate supply
Staff
Resident Initials
Ensure laundry has been completed, folded, and/or hung up as appropriate
Staff
Resident Initials
Hand and foot checks; assist with nail trimming if necessary.
Note any concerns below.
Staff
Resident Initials
What was discussed? Include comments, individual’s concerns, goals for upcoming week:
Primary DSP Checklist
Individual
*
Date
*
Location
*
Staff Name
*
Review of Outcomes (from individual’s book)
Outcome #1
Completed prior week:
Yes
No
Outcome #2
Completed prior week:
Yes
No
Outcome #3
Completed prior week:
Yes
No
Outcome #4
Completed prior week:
Yes
No
Weight:
* Weight must also be recorded in the Health Progress Notes
Room Check - Ensure room is neat and clean, no inappropriate or unsafe items
Staff
Resident Initials
Review schedule of activities for the week
Staff
Resident Initials
Check personal hygiene items, clothing, etc. to be sure they have an adequate supply
Staff
Resident Initials
Ensure laundry has been completed, folded, and/or hung up as appropriate
Staff
Resident Initials
Hand and foot checks; assist with nail trimming if necessary.
Note any concerns below.
Staff
Resident Initials
What was discussed? Include comments, individual’s concerns, goals for upcoming week:
Submit