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 Page de gard= e   Page 1.4   Page 2.4   Page 3,4   Page4,4   Page qualico= mm à retourner   Page qualico= mm 
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<= /td> Alliance Servic= es Ardennes 
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<= /td> Cahier de liaison 
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Cliquez sur= les onglets pour plus de détail 
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Alliance Services Ardennes         &nbs= p;              &nbs= p;   paRCE QU ON EST MIEUX CHEZ SOI  Document de P= rise en Charge Personnalisée  Date     
Date DPCP Précédent   
Page 1/4  Contrat de référence:  
RENSEIGNEMENTS ADMINISTRATIFS 
<= /td>
BENEFICIAIRE      INTERLOCUTEURS  HABITUELS 
       
Nom: Avril    Médecin Généraliste : Dr Knock  
       
Prénom: Micheline    Kinésith= érapeuthe : M. Fabercastel  
       
    Infirmière: Mme Anderson   
Adresse : 4 rue des bégonias       
       
    Organismes inte= rvenants :  
Téléphone : "032426160= 9      
    Interlocuteur := Mme Toulon ( Fi= lle )  
       
Date de naissance: 01/01/1930   Caiise de retra= ite : CRAM  
       
    Sécurit&= eacute; sociale : 20830……   
Age : 77 ans       
    Mutuelle : Alteis   
       
                                 
DEPENDANCE  INTERLOCUTEURS Alliance Services Ardennes <= /td>
       
       
Cotation GIR  2   Bureaux : 03 24 26 16 09 : Mme Cagny   
       
Date : 01/04/2006   Responsable: 03 24 26 16 09 : Mme Jacquet   
       
Autres éléments :   Intervenants :<= /td> Mmes Edmond/ Micholet   
       
       
                                 
Bénéficiaire Cont= acts ( Nom et téléphone )
&nb= sp;              
Nom   Médecin  
       
Prénom   Infimier  
       
Age<= span style=3D'mso-spacerun:yes'>    Kiné  
       
Adresse   Personne de Con= fiance  
   
   
Télép= hone      
=
=
Intervanants ASA 
&nb= sp;      
Responsable  
Intervenant  (s)  
   
       
=
=
Dé= pendance et prise en charge 
&nb= sp;      
GROUPE GIR   
APA (O/N)  
Mutuelle  
Caisse retraite     
=
Enqûete annuelle à réaliser par 
Courrier      Tél&ea= cute;phone Domicile Agence 
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Alliance Services Ardennes         &nbs= p;              &nbs= p;   paRCE QU ON EST MIEUX CHEZ SOI  Document de P= rise en Charge Personnalisée  Date     
Date DPCP Précédent   
Page 2/4     
OBJECTIFS DU PLAN D'AIDE : Tâches ménagères 
<= /td>
ENTRETIEN DE LA MAISON      ENTRETIEN DU LINGE 
       
       
Besoins estimé , nature des tâches et volume d'heures :   Besoins estim&e= acute; , nature des tâches et volume d'heures :  
       
       
  Ménage de quatre  heures par semaine d= ont :     Fait par enfants   
  Moquette salon  1f/ semaine       
  Réfrigérate= ur 1f/ mois       
  Vitres 1 fois par mois       
       
       
Souhaits émis par la personne bénéficiaire :    Souhaits émis par la personne bénéficiaire :   
       
  Ranger les cour= ses après les livraisons ( 1 fois par mois)      
       
Décision :    Décision :   
       
  RAS      
                                 
PREPARATION DES REPAS  AUTRES 
       
       
Restrictions particulières ( régimes … )   Modalité de réalisation de l'enqûete qualité annuelle : (Par défaut l'enqûete sera envoyée 
    par courrier au= domicile du bénéficiaire )  
       
  Régime diabétique : Suivre avec Infirmière et noter sur le cahier<= span style=3D'mso-spacerun:yes'>    Préfere = 1 visite au domicile  
       
       
       
Souhaits émis par la personne bénéficiaire :       
       
       
  Aime la soupe = de légume mais sans navets       
       
       
       
       
                                 
Bénéficiaire Cont= acts ( Nom et téléphone )
&nb= sp;              
Nom   Médecin  
       
Prénom   Infimier  
       
Age<= span style=3D'mso-spacerun:yes'>    Kiné  
       
Adresse   Personne de Con= fiance  
   
   
Télép= hone      
=
=
Intervanants ASA 
&nb= sp;      
Responsable  
Intervenant  (s)  
   
       
=
=
Dé= pendance et prise en charge 
&nb= sp;      
GROUPE GIR   
APA (O/N)  
Mutuelle  
Caisse retraite     
=
Enqûete annuelle à réaliser par 
Courrier      Tél&ea= cute;phone Domicile Agence 
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Alliance Services Ardennes         &nbs= p;              &nbs= p;   paRCE QU ON EST MIEUX CHEZ SOI  Document de P= rise en Charge Personnalisée  Date  01/04/2006  
Date DPCP Précédent  //
Page 3/4     
OBJECTIFS DU PLAN D'AIDE : Aide à la personne 
Be= soins exprimés par le bénéficiaire :                           
   
  Aide journalière à la toilette avec une douche 2 fois par semaine   
  Aide à la préparation des repas chaque jour , à coordonner avec les injections d'insulins   
   
                                 
<= /td>
ACTIONS DECIDEES  Fr&= eacute;quence Qui ( 1)  Beso= ins V. Henderson
<= /td> 1. Respirer  
      2. Boire et man= ger  
2 : Boire et manger : Préparer le petit déjeuner et servir dès l'injection : Voir systématiquement IDE  Ma/Mi/Soir Faire  3. Élimi= ner  
                    4. Se mouvoir et se maintenir en bonne posture
3 : Aider à aller aux toilettes : Vider et nettoyer la chaise percée      Ma/Mi/soir  Faire  5. Dormir et se= reposer  
      6. Se vêt= ir et se dévêtir  
3 : Personne sujette à la constipation : noter sur le cahier les sel= les : Alerter si constipation  Journalière Faire  7. Maintenir sa température dans les limites normales
                    8. Être propre, soigner et protéger ses téguments
8 : Aide à la toilette avec douche deux fois par semaine : Utiliser siège de douche    Mardi et Ve Aider  9. Évite= r les dangers  
      10. Communiquer avec ses semblables
10 : Le dimanche , aime regarder les émissions religieuses : Interven= ir avant 10 heures et installer  1f/ Semaine  Aider  11. Agir selon ses valeurs et ses croyances
                    12. S'occuper en vue de se réaliser
12 : Lui apporter le jou= rnal le matin            Jour&nb= sp; Faire  13. Se récréer  
      14. Apprendre  
     
                   
                   
     
     
                   
                   
                   
<= /td>
(1) : Indiquer dans cette colonne - Faire ou aider à faire 
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Plan d'intervention détaillé - page 4/4
Ac= tion  Interv= enant  Jour Horaire  Faire /Aider à faire  Remarques
Petit déjeuner + aide à la toilette    Chaque jour  8h00 à= 9h00 Faire   
Douche    Mardi    Aider  Shampoing
Douche    Vendredi    Aider  Shampoing
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Préparer et servir repa= s    Chaque jour sauf dimanche  12h30 à= ; 13h30 Faire  Dimanche avec sa famille le midi 
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Coucher + petite toilette    Chaque jour  20h30 à= ; 21h00 Aider   
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Souhaits divers émis par le bénéficiaire  Mod= alités de coordination
       
       
         
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ENREGISTREMENT DES INTERVENTIONS       &n= bsp;      Page à retourner à Alliance Services Ardennes
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ENREGISTREMENT DES INTERVENTIONS 
DATE=   INTERVENANT = HEURE DEBUT / FIN  TACHE ACCOMPLIE TRANS= MISSION  VISA INTERV.  VISA Client
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