Formularios de mantenimiento de registros

Encuentre los formularios necesarios y el software electrónico aprobado para el mantenimiento de registros en un hogar de cuidado para adultos.

En esta página

Libro de Registros Comerciales
Libro de Registros de Residentes
Registros de administración de medicamentos
Carpeta de planificación de preparación para emergencias
Solicitudes de excepción
Formularios para operadores y administradores residentes
Solicitud de reclasificación
Software electrónico para el mantenimiento de registros

Libro de Registros Comerciales

Business Records Book Cover Sheet (12.87 KB)

Business Records Table of Contents (116.99 KB)

Caregiver Employment Notification (82.3 KB)

Caregiver Qualifications and Training Log (optional) (34.34 KB)

Caregiver Checklist (96.83 KB)

Caregiver Workbook Certificate (72.97 KB)

Fax Cover Sheet (optional) (60.25 KB)

Operator Visiting Log (Optional) (122.26 KB)

Staffing Plan (170.33 KB)

Staffing Plan Excel Form (10.77 KB)

Menu Template (742.59 KB)

Emergency Phone List (11.65 KB)

Fire/Evacuation Drill Record updated 4-12-2017 (82.91 KB)

Backup Operator (102.94 KB)

Smoke Alarm & Carbon Monoxide Detector Monthly Test Log (299.36 KB)

Opioid Overdose Daily Checks Monthly Log (168.28 KB)

Libro de Registros de Residentes

Resident Records Books Cover Sheet (570.76 KB)

Resident Records Table of Contents - APD and MHA (116.35 KB)

Residency Agreement Sample Medicaid (457.58 KB)

Residency Agreement Sample ElderPlace (456.99 KB)

Residency Agreement Sample Private Pay (683.02 KB)

Classification Worksheet (171.32 KB)

APD and MHA Resident Screening Sheet (260.6 KB)

Resident Re-Screening Sheet (112.88 KB)

Resident Information Sheet (113.21 KB)

Long Term Care Assessment Notice (94.36 KB)

Resident Personal Possessions Inventory (126.77 KB)

Residents' Bill of Rights (99.94 KB)

Nondiscrimination Policy (55.11 KB)

APD Resident Bed Rail Acknowledgment (49.64 KB)

Si el archivo no se muestra en el navegador, descargue el archivo:

Fillable APD Form 0556 Individual Consent to HCBS Limitations (IBL) (1.79 MB)

Solo para residentes que pagan de forma privada:

Non-fillable APD Form 0556 Individual Consent to HCBS Limitations (IBL) (972.81 KB)

Notice of Involuntary Move (197.81 KB)

Activity Log (249.39 KB)

APD-MHA Care Plan updated 5-4-2017 (1 MB)

Commonly Used Abbreviations (15.36 KB)

Recommended Day Care Relative Care Request Form (20.94 KB)

Weekly Progress Notes (176.52 KB)

Incident Report (338.02 KB)

Individual Financial Record (110.4 KB)

Authorization to release confidential information (11.92 KB)

RN or Physician Monitoring Checklist (111.76 KB)

Resident Orientation to Fire & Safety in the Adult Care Home (103.38 KB)

Registros de administración de medicamentos

Cover Sheet for MAR Book (37.51 KB)

Table of Contents For MAR Book (104.75 KB)

MAR-PRN Form (193.76 KB)

Physician order form updated 3.27.2018 (103.97 KB)

PRN Guideline (102.3 KB)

Controlled Substance Count Sheet (428.83 KB)

Medication Disposal Record Form (133.1 KB)

Commonly Used Medical Abbreviations (97.41 KB)

MAR Book - Packet of All Forms (906.11 KB)

Lista de sustancias controladas de la DEA

Carpeta de planificación de preparación para emergencias

Cover Page for EPP Binder (49.35 KB)

EPP Table of Contents (81.88 KB)

Emergency Preparedness Plan (517.24 KB)

Adult Care Home Relocation Form (265.54 KB)

MAR-PRN Form (193.76 KB)

Resident Emergency Contact Card (63.02 KB)

Adult Care Home Emergency Phone List (Back Cover) (64.83 KB)

Solicitudes de excepción

Exception Request General (74.39 KB)

Exception Request for Out Of Class Resident (92.68 KB)

Request for More than One Bedbound Resident (89.12 KB)

Interagency Placement Exception Request (398.1 KB)

Exception Request Ramps (98.04 KB)

Exception Request to 72 inch rule (98.36 KB)

Vacation or Absence From Home Request (337.47 KB)

Resident Manager Exception Request (207.57 KB)

Shift Managers Exception Request (96.14 KB)

Formularios para operadores y administradores residentes

Provider Enrollment Agreement (260.82 KB)

Real Estate Form (117.83 KB)

Operator/Resident Manager Health History and Physician/Nurse Practitioner Statement (326 KB)

Proposed Operating Budget (812.42 KB)

Professional Character Reference (391.35 KB)

Resident Manager Change Request (103.96 KB)

Sample Job Application (126.13 KB)

APD and BH Self Audit Tool (1.02 MB)

Solicitud de reclasificación

APD Level 3 Reclassification Request (142.16 KB)

APD Class 3 Medical Professional Reference (72.05 KB)

APD or MHA Class 2 Reclassification Request (144.01 KB)

Software electrónico para el mantenimiento de registros

Se requiere una excepción para el uso de software electrónico para el mantenimiento de registros. Todo software debe ser aprobado por el ACHP. Estos programas han sido evaluados para cumplir con los criterios del ACHP:

Si está interesado en utilizar un software diferente, deberá ser revisado y aprobado por ACHP antes de su uso.

Last reviewed February 12, 2026

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