PLANIDVUZ

PLAN INDIVIDUALIZAT DE SERVICII

Nr. ______ / _____________

1.sDate de identificare a rezidentului:

Numele i prenumele
rezidentuluilui:_________________________________________________________________
Locul i data
naterii:______________________________________________________________________
CNP:________________________________________________________________________
Fiul/fiica lui:___________________________________________________________________
Domiciliul stabil:_______________________________________________________________
Reedina____________________________________________________________________
Studii:____________________________________Ocupia:____________________________
Diagnostic____________________________________________________________________
Gradul de dependen : IA, IB, IC; IIA,IIB,IIC; IIIA, IIIB
Dispozitie de internare
nr.______________/_______________ Cminul pentru persoane vrstnice Ing. Vadim
Rusu
Stare civil________________________ Nr. copii____________________________________
2.b/s:paopdzbzaRtott:a._____________/____________
Manager de caz:
____________________________________________________________________________
Echipa multidisciplinar:
Componen:
Specialitatea:
1. Asistent social
Asistent social
2. Asistent medical
Asistent medical
generalist
3. Medic
Medicin de familie
4. Psiholog
Psihologie
5. Animator
Animaie socioeducativ
6. Infirmier

7. Personal voluntar: preot

Teologie pastoral

3.bgtFtGazazCz:p:pPFFzIF :.
telefon

SECIUNI :

A.bPROGRAM INDIVIDUALIZAT DE ASISTEN I NGRIJIRE

M anager de caz: asistentul social
B.bPROGRAM INDIVIDUALIZAT DE RECUPERARE
M anager de caz: Medic
C.bPROGRAM INDIVIDUALIZAT DE INTEGRARE /REINTEGRARE SOCIAL
M anager de caz: asistentul social

D.bPROGRAM INDIVIDUALIZAT DE IEIRE

M anager de caz : asistentul social

NOT:

Activitile se planific pe o perioada de 6 luni corespunzator rezultatelor

evalurii iniiale respectiv ultimei reevaluri, conform legii.
Schimbarea termenului de valabilitate a programului se poate face ori de
cate ori intervin situaii de natur s modifice serviciile de ngrijire specifice
eneficiarului.

A.sPROGRAM INDIVIDUALIZAT DE ASISTEN I NGRIJIRE

I.b.zaRtottatsatpazazCPFppzdt:zRFPazGazzRFPazD
1.bServicii sociale:
Gzduire pe perioad
nedeterminat
Hran
Sprijin cotidian/ajutor pentru menaj

Consiliere psihologic
Consiliere administrativ
Consiliere juridic

2.bServicii socio-medicale i de ngrijire:

Servicii de ingrijire
personal
Sprijin pentru igiena
corporal
Imbracare si dezbracare
Igiena eliminrilor
Hrnire i hidratare
Deplasare interior/exterior

Servicii de ngrijiri medicale primare

Efectuarea msurtorilor
antropometrice
Monitorizarea parametrilor fiziologici
Efectuarea de imunizri
Programe de ergoterapie
Activitti de consiliere i suport

II.Alte servicii specifice beneficiarului: NcULcEDA PLAPNIANDVUZPTPZAN

personal pentru persoana dependentF)aj=

IIISActiviti planificate n vederea furnizrii serviciilor de ngrijire :

Activitatea
Servicii sociale
Servicii sociomedicale i de
ngrijire
Alte servicii

Durata /
Perioada
Permanent
Permanent
Permanent

Responsabil

Resurse

Asistent social,
psiholog, jurist,
ngrijitoare
Animator, Asistent
social, Asistent medical,
Infirmier
Infirmiera

Resurse
umane interne
Resurse
umane interne
Resurse

specifice

umane interne

Ob ervaiin
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
________________________________________
M anager de caz,
Asistent social,

B.be_;_ Bcmimn f, Nmr_r/ner_ _r

I.sServicii prioritare rezultate din evaluare / reevaluare:
1.bServicii medicale:
Consultaie medical lunar i la nevoie
Tratamente medicale pentru boala cronic
Acordarea de materiale sanitare
Asigurarea medicamentelor
Administrarea medicamentelor
Facilitarea achizitionrii unor dispozitive medicale
Facilitarea unor consultaii i ngrijiri specializate
Servicii de recuperare i reabilitare conexe domeniului social i
medical:kineto/fizio terapie, masaj etc.
2. Servicii de recuperare:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
3. Alte servicii specifice beneficiarului (activiti de refacere/meninere a abilitilor
de autoservire,ngrijire personal/ autogospodrire prin programe de ergoterapie, exerciii
fizice etc):
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
II.sActiviti planificate n vederea furnizrii serviciilor de ngrijire:
Activitatea
Durata / PerioadabResponsabil
Resurse

Servicii medicale

Permanent

Servicii de
recuperare
Alte servicii specifice

Medic

Interne

Medic specialist

Externe

Medic
Asistent medical

Interne

Ob ervaiin
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
M ANAGER DE CAZ:
Medic,
C.be_;_ Bcmimn f, NmrcNr_ _rG_rcNr_ _r.;/ fv
I.sServicii prioritare rezultate din evaluare/ reevaluare:
Servicii de
integrare/reintegrare sociofamilial
Sprijin pentru
conceperea/trimiterea unor
scrisori ctre familie, prieteni
Facilitarea accesului la telefon
etc.
Sprijin pentru meninerea
legturii cu familia, vecinii etc.
prin consiliere, coresponden,
telefon, ieiri n comunitate
etc.
Sprijin pentru organizarea unor
vizite n familie /comunitate
/cunotinte, conform
procedurilor

Servicii de integrare social n comunitate

(mediul intern, mediul extern)
Organizarea srbtorilor naionale/religioase
Organizarea manifestrilor tradiionale (ziua
de natere, ziua numelui)
Organizarea unor activiti de loisir (de
petrecere a timpului liber)

Organizarea unor activiti cultural/artistice

i alte activiti recreative, in parteneriat cu
alte instituii
Informare n vederea cunoaterii/utilizrii
serviciilor comunitii:pot i comunicaii,
transport, servicii medicale etc.

II.sActiviti planificate n vederea furnizrii serviciilor de ngrijire:

Activitatea

Durata /

Responsabil

Resurse

Activiti de loisir
socializare i
cunoastere/intercunoas
tere
Activiti moral
religioase/cult liturgic
Facilitarea meninerii
legturii cu familia prin
consiliere, discuii
telefonice, etc.

Perioada
Permanent

Permanent

Permanent

Diveri parteneri
Asistent
social/animator
Asistent medical
Diveri parteneri
(reprezentani ai
Bisericii)
Asistent social
Asistent medical

Resurse
umane
externe/intern
e
Resurse
umane
externe/intern
e
Resurse
umane
interne/extern
e

Ob ervaiin
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________
____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
__________________________________________________________
M anager de caz,
Asistent social,
D. PROGRAM INDIVIDUALIZAT DE IEIRE

Data ieirii: RRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRR

Tipul ieirii:
a.bTransfer la o alt unitate de asisten social
.bReintegrare n familie (locuina proprie etc.)
c.bDeces
d.bAlte situaii (trai independent n comunitate etc.)
_____________________________________________________________________________________
___________________________________________________________________
Cine solicit ieirea:
a) beneficiarul
) familia
c) ali susintori legali: _________________________________________________________
d) alte instituii: ________________________________________________________________
e) alte situaii: ________________________________________________________________

sistent social,

Estimarea posibilitii de ieire :

a) conform planificrii i procedurilor
) prelungirea cu 6 luni a termenului
c) alte situaii:
_____________________________________________________________________________________
_____________________________________________________________________________________
__________________________________________________________
Condiiile n care se va efectua ieirea beneficiarului:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
__________________________________________________________
Servicii de sprijin dup ieire: DPUpVUPEPrA.PFIi1EVVAtEVUAVUiPEDPdV1.AroVoiPUi1.1VA
social responsabil de caz, din cadrul D.G.A.S.P.C Ialomia Serviciul de asisten
social pentru aduli sau din cadrul unitii de asisten social/din cadrulS.P.A.Sl
Ob ervaiin
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
M anager de caz,
A