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Family Caregiver Documentation & Care Plan
Family Caregiver Documentation & Care Plan Template
For Families Seeking State-Funded or Medicaid Paid Caregiver Programs
Purpose: This template helps document care needs, caregiver activities, and service hours commonly required for Medicaid waiver programs, consumer-directed care programs, and other state-funded caregiver programs.
CLIENT INFORMATION
Care Recipient Information
Name: ______________________________________
Date of Birth: _______________________________
Address: ____________________________________
Phone: _____________________________________
Medicaid ID (if applicable): ____________________
Primary Physician: ___________________________
Physician Phone: ____________________________
Emergency Contact: __________________________
Relationship: _______________________________
Phone: _____________________________________
CAREGIVER INFORMATION
Caregiver Name: _____________________________
Relationship to Recipient: _____________________
Phone: _____________________________________
Email: ______________________________________
Start Date of Caregiving: ______________________
Hours Available Weekly: ______________________
MEDICAL CONDITIONS
Check all that apply:
☐ Dementia/Alzheimer’s
☐ Stroke
☐ Diabetes
☐ Heart Disease
☐ COPD
☐ Cancer
☐ Arthritis
☐ Mobility Limitations
☐ Vision Impairment
☐ Hearing Impairment
☐ Mental Health Diagnosis
☐ Developmental Disability
☐ Other: ____________________________
Additional Notes
ACTIVITIES OF DAILY LIVING (ADLs)
Activity
Independent
Needs Some Help
Fully Dependent
Bathing
☐
☐
☐
Dressing
☐
☐
☐
Grooming
☐
☐
☐
Toileting
☐
☐
☐
Eating
☐
☐
☐
Walking/Transfers
☐
☐
☐
Notes
INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADLs)
Task
Independent
Needs Help
Meal Preparation
☐
☐
Shopping
☐
☐
Housekeeping
☐
☐
Laundry
☐
☐
Transportation
☐
☐
Medication Reminders
☐
☐
Managing Finances
☐
☐
Scheduling Appointments
☐
☐
MEDICATION TRACKER
Medication
Dosage
Time Given
Notes
DAILY CARE LOG
Date: ___________________
Morning Care
☐ Assisted with bathing
☐ Assisted with dressing
☐ Medication reminder
☐ Breakfast prepared
☐ Mobility assistance
Notes:
Afternoon Care
☐ Lunch prepared
☐ Transportation
☐ Exercise/therapy assistance
☐ Medication reminder
☐ Housekeeping
Notes:
Evening Care
☐ Dinner prepared
☐ Personal hygiene assistance
☐ Medication reminder
☐ Safety check
Notes:
CARE HOURS TRACKER
Date
Start Time
End Time
Total Hours
Tasks Performed
Weekly Total Hours: __________
INCIDENT & SAFETY REPORT
Date of Incident
Type of Incident
☐ Fall
☐ Wandering
☐ Medical Emergency
☐ Behavioral Episode
☐ Medication Issue
☐ Other
Description
Action Taken
APPOINTMENT TRACKER
Date
Provider
Purpose
Follow-Up Needed
MONTHLY CARE SUMMARY
Changes in Health
New Limitations
Increased Care Needs
Estimated Hours of Care This Month
Caregiver Signature
Date
Documents to Keep Together
Maintain copies of:
  • Medicaid approval letters
  • Physician statements
  • Diagnosis records
  • Medication lists
  • Hospital discharge paperwork
  • Therapy reports
  • Timesheets
  • Care logs
  • Care assessments
  • Caregiver training certificates
  • State program correspondence
Pro Tip
When seeking approval for a paid family caregiver program, the strongest evidence is often:
  1. Detailed daily care logs.
  2. Consistent hour tracking.
  3. Documentation showing assistance with ADLs (bathing, dressing, toileting, mobility, eating).
  4. Physician documentation supporting the need for ongoing care.
Keeping this template updated daily can significantly strengthen an application or reassessment for state-funded caregiving services.
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Tezzie Gilbert
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Family Caregiver Documentation & Care Plan
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