INITIAL PLAN OF CARE

FOR VA PCS VETERANS

Date of Assessment:

This initial plan of care must be faxed to

VA and approved before a start of care
date will be provided.
Community Care Program:
Please fax or email securely to: 254-743-0184 ;
Ctx_pcs_ctxpcs@va.gov
Agency name:

Agency contact person:_

Agency phone number:

CENTRAL TEXAS VA HEALTHCARE SYSTEM PATIENT:

Name:
Social Security #:
Address:
City/State:
Physician:
Primary Diagnosis:

VETERAN'S SCHEDULE (Actual hours scheduled for care):

H/HHA
Sun Mon Tues Wed Thurs Fri Sat

Respite
Sun Mon Tues Wed Thurs Fri Sat

Describe Veteran's symptoms and physical limitations which cause need for personal
care:

1
Describe Veteran's mental/emotional/cognitive condition: ______

Assistive devices used by Veteran/Adaptive devices in the home:

Personal care tasks to be performed every visit:

H/HHA: __________________________________________________________________________
__________________________________________________________________________________

Respite: _________________________________________________________________
________________________________________________________________________

Discharge goal:

Other services Veteran is receiving i.e. skilled nursing, Meals on Wheels etc.

Family support: _____________________________________________________________

__________________________________________________________________________

___________________________________________________________________________________

Signature of Veteran or responsible party:

Signature of person doing assessment:

Signature of RN approving plan of care:

(You may include any other pertinent information with your fax)