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Sample Weekly Care Notes
Per COMAR 10.07.14.27D:
D. Resident Care Notes.
(1) Appropriate staff shall write care notes for each resident:
(a) On admission and at least weekly;
(b) With any significant changes in the resident's condition, including
when incidents occur and any follow-up action is taken;
(c) When the resident is transferred from the facility to another skilled
facility;
(d) On return from medical appointments and when seen in home by any
health care provider;
(e) On return from nonroutine leaves of absence; and
(f) When the resident is discharged permanently from the facility,
including the location and manner of discharge.
(2) Staff shall write care notes that are individualized, legible, chronological,
and signed by the writer.
The following are three (3) samples of forms that may be used to
satisfy the weekly care note requirement. Please note that these
forms are not meant to be all inclusive; if warranted, additional
information may be required. In addition, these samples may not be
used for the admission, transfer, or discharge notes. If your program
already maintains a resident record (daily or otherwise) that meets all
the requirements set forth in COMAR 10.07.14.27D, you do not need
to write a duplicate weekly note (provided a note is already written
for each resident at least weekly).
ABC Assisted Living WEEKLY CARE NOTES
Resident Name_______________________________________
Date ____________ Has this resident had any medical issues or cognitive changes in the past week? Yes ____ No ____ If yes, please see nurses notes.
Has the resident had any new orders in the past week? Yes ____ No ____ If yes, please see physician’s orders. Has the resident had any changes in ADL function? Yes ____ No ____ If yes, please explain and change Service plan if needed.
Has the resident had any tests or labs done in the past week? Yes ____ No ____ If yes, see lab/x-ray section of the chart. Comments: ________________________________________________________________________________
Nurses signature: _________________________________________________
Date ____________ Has this resident had any medical issues or cognitive changes in the past week? Yes ____ No ____ If yes, please see nurses notes.
Has the resident had any new orders in the past week? Yes ____ No ____ If yes, please see physician’s orders. Has the resident had any changes in ADL function? Yes ____ No ____ If yes, please explain and change Service plan if needed.
Has the resident had any tests or labs done in the past week? Yes ____ No ____ If yes, see lab/x-ray section of the chart. Comments: ________________________________________________________________________________
Nurses signature: __________________________________________________
XYZ Assisted Living
Weekly Care Note
Resident: ____________________________________ Month: _________________________________
Week: _______________________________
Changes in medication? yes no n/a Changes in food intake? yes no n/a Changes in behavior? yes no n/a Changes in mental status? yes no n/a Falls? yes no n/a Skin Issues? yes no n/a Constipation Issues? yes no n/a Insomnia problems? yes no n/a Hospitalizations/ER Visits? yes no n/a Doctor Appointments? yes no n/a Other changes to care? yes no n/a
Explain any items marked yes above. Were these reported to the ALM and/or Delegating Nurse? Also document any other observations.
_______________________________________________Signature:__________________________________
Week: _______________________________
Changes in medication? yes no n/a Changes in food intake? yes no n/a Changes in behavior? yes no n/a Changes in mental status? yes no n/a Falls? yes no n/a Skin Issues? yes no n/a Constipation Issues? yes no n/a Insomnia problems? yes no n/a Hospitalizations/ER Visits? yes no n/a Doctors Appointments? yes no n/a Other changes to care? yes no n/a
Explain any items marked yes above. Were these reported to the ALM and/or Delegating Nurse? Also document any other observations.
___________________________________________________Signature:______________________________
