BH NEGOTIATED SERVICE AGREEMENT
NAME:
Age:
Birthdate:
Assessment Location:
Marital Status:
Children’s names:
NICKNAME:
Place of birth:
Gender:  M  F
Living arrangements:
Spouse’s name:
Maiden name:
Primary Contact Person:
Relation:
Address:
Phone #:
Social Security #:
Medicare #:
Medicaid #:
Veteran:  Y 
N
Primary Health insurance:
Pre-authorization required:
Other insurance coverage:
 Y  N
SUBSTITUTE DECISION MAKER:  Y  N
Name:
Scope of decision-making capabilities:
Primary Care Provider:
Clinic Address:
SPECIALIST:
SPECIALIST:
DENTIST:
PHARMACY:
Preferred Hospital:
Branch of Service:
Policy #:
Phone #:
Policy #:
(If yes, provide a copy to the facility)
Phone:
Phone:
Phone:
Phone:
Phone:
Phone:
Phone:
Fax:
Fax:
Fax:
Fax:
Fax:
ADVANCE DIRECTIVES:  Y  N (If yes, provide a copy to the facility)
Funeral Arrangements?  Y  Funeral Home:
Phone #:
N
Current Height (ft/in):
Blood Pressure:
Current Weight (lb):
 Recent change? Explain:
Pulse:
Resp:
RESIDENT NAME: _______________________________________________
Temp:
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BH NEGOTIATED SERVICE AGREEMENT
CARE AND SERVICES
COMMUNICATION:
SPEECH/HEARING/VISION
Problems with speech
Describe:
Yes
RESIDENT STRENGTHS/WHAT
RESIDENT PREFERS TO DO
INDEPENDENTLY
WHAT PROVIDER/CAREGIVER/SUPPORT
PERSON DOES/WHEN & HOW
No
Hearing problems
Describe/aid:
Visual problems
Describe/aid:
Telephone Use
Independent
Assistance
Dependent
Language:
Describe
MEDICATION MANAGEMENT:
SELF ADMINISTRATION (Check all that apply)
Oral
Sprays
Topical
Injections
Eye drops/ointments
Allergy Kits
Inhalers
Keep Own Meds
SELF MEDICATION W/ASSISTANCE
Oral
Topical
Eye drops/ointments
Inhalers
Sprays
Allergy Kits
Meds Organizer
Equipment:
RESIDENT NAME: _______________________________________________________________________
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BH NEGOTIATED SERVICE AGREEMENT
CARE AND SERVICES
ADMINISTRATION
Nurse Delegated?
Oral
Topical
Eye drops/ointments
Inhalers
Injections
Yes
RESIDENT STRENGTHS/WHAT
RESIDENT PREFERS TO DO
INDEPENDENTLY
WHAT PROVIDER/CAREGIVER/SUPPORT
PERSON DOES/WHEN & HOW
Yes
No
Sprays
Allergy Kits
Meds Organizer
Equipment:
No
If yes:
By family
Licensed professional
Medication plans when resident not in home:
TREATMENT/PROGRAMS/THERAPIES
Health issues to monitor:
Yes
No
Oxygen Use
Pain
Weight Loss/Gain
Programs the resident attends, such as adult day health
Nursing Consultation/Treatments
RN Delegation
What tasks:
Yes
No
Consent
Physical Enablers:
RESIDENT NAME: _______________________________________________________________________
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BH NEGOTIATED SERVICE AGREEMENT
CARE AND SERVICES
PSYCH/SOCIAL/COGNITIVE STATUS
Sleep disturbance
Memory impairment (Short-term)
Memory impairment (Long-term)
Decision making
Disruptive behavior
Assaultive
Resistive
Depression
Anxiety
Disorientation
Wandering in home
Exit seeking
Hallucinations
Delusions
If yes, describe:
Requires psychopharmacological
medications
If yes, describe symptoms for each
medication
STANDARD PRECAUTIONS
Yes
No
RESIDENT STRENGTHS/WHAT
RESIDENT PREFERS TO DO
INDEPENDENTLY
What resident does
Describe behaviors – be specific:
WHAT PROVIDER/CAREGIVER/SUPPORT
PERSON DOES/WHEN & HOW
Describe specific non-medication
(behavioral/environmental) interventions to
address the symptoms
Caregiver will use latex/plastic gloves when
in contact with any secretions to prevent
spread of infection. Thorough hand washing
with soap will be done before and after
gloving. Gloves will be put on and discarded
at the end of each task.
RESIDENT NAME: ____________________________________________________________________
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BH NEGOTIATED SERVICE AGREEMENT
CARE AND SERVICES
RESIDENT STRENGTHS/WHAT
RESIDENT PREFERS TO DO
INDEPENDENTLY
WHAT PROVIDER/CAREGIVER/SUPPORT
PERSON DOES/WHEN & HOW
MOBILITY
In room & immediate living environment:
Independent
Assistance
Dependent
Outside of immediate living environment (to include
outdoors):
Independent
Assistance
Dependent
Equipment:
Preferences/Choices:
BED MOBILITY/TRANSFER
Independent
Assistance
Dependent
Skin care due to inability to position self:
Equipment/supplies:
Risk for falls:
Preferences:
Enablers:
Safety assessment, alternatives explored; how to keep
resident safe:
Night time care needs:
EATING
Independent
Assistance
Special diet/supplements:
Dependent
Eating habits
Food allergies
Preferences/equipment
RESIDENT NAME: ______________________________________________________________________
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BH NEGOTIATED SERVICE AGREEMENT
CARE AND SERVICES
RESIDENT STRENGTHS/WHAT
RESIDENT PREFERS TO DO
INDEPENDENTLY
WHAT PROVIDER/CAREGIVER/SUPPORT
PERSON DOES/WHEN & HOW
TOILETING/CONTINENCE ISSUES
Independent
Assistance
Dependent
Bladder incontinence
Yes
No
Occasional
Bowel incontinence
Yes
No
Occasional
Skin care due to bowel/bladder incontinence:
Equipment:
Preferences:
DRESSING
Independent
Equipment:
Assistance
Dependent
Preferences:
PERSONAL HYGIENE
Independent
Assistance
Oral hygiene, including dentures:
Dependent
When and how often:
Preferences:
BATHING
Independent
How often:
Assistance
Dependent
When:
Equipment:
Preferences:
RESIDENT NAME: ______________________________________________________________________
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BH NEGOTIATED SERVICE AGREEMENT
CARE AND SERVICES
RESIDENT STRENGTHS/WHAT
RESIDENT PREFERS TO DO
INDEPENDENTLY
WHAT PROVIDER/CAREGIVER/SUPPORT
PERSON DOES/WHEN & HOW
BODY CARE (Foot care, skin care, nail care, range of
motion, dressing changes)
Independent
Assistance
Dependent
Foot care:
Yes
No
Skin problems:
Yes
No
Describe:
Dressing changes:
Nurse delegated:
Yes
Yes
No
No
Skin care:
How often:
Preferences:
MANAGING FINANCES
Independent
Assistance
Dependent
Who manages finances:
Financial records:
Preferences:
SHOPPING
Independent
Assistance
Dependent
Special transportation needs:
How often:
Preferences:
RESIDENT NAME: ___________________________________________________________________
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BH NEGOTIATED SERVICE AGREEMENT
TRANSPORTATION
Independent
Assistance
Medical services:
Dependent
Special transportation needs:
Equipment:
How often:
Preferences:
ACTIVITIES/SOCIAL NEEDS
Independent
Assistance
Dependent
Interests/Activities/Religious Activities:
Social/Cultural Traditions/Preferences:
Family/Friends/Relationships:
Employment Support:
Clubs/Groups/Day Health:
Emergency Numbers Provided:
Special Arrangements:
Participation Issues
SMOKING
Yes
No
Safety Concerns:
Preferences:
RESIDENT NAME: ___________________________________________________________________
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BH NEGOTIATED SERVICE AGREEMENT
CASE MANAGEMENT
Contact the case manager when:
 The resident needs assistive device or
other services to meet the needs
 Significant changes with the
condition/needs that necessitate changes
with this service agreement
OTHER ISSUES/CONCERNS/PROBLEMS
WAC 388-78A-2130 - 2160 Negotiated Service Agreement: Brief instructions based on WAC
(1) Developed within 30 days of admission based on the Assessment and the Initial Resident Service Plan.
(2) Describes/identifies: (a) The services to be provided; (b) Who will provide the services; and (c) When and How the services will be provided.
(3) Designed to meet the Resident’s Needs, Preferences, and Choices.
(4) Developed with input from the Resident and/or the Resident’s Representative / Surrogate Decision Maker, appropriate professionals, and the
case manager, if applicable
(5) Agreed to, Signed and Dated by the Resident and/or the Resident’s Representative / Surrogate Decision Maker, appropriate professionals, and
the provider.
(6) The signed copy of the plan must be given to the Case Manager if Resident is receiving services paid for fully or partially by the department.
(7) Reviewed and Revised: (a) at least every 12 months; (b) upon any significant change in Resident’s physical, mental, or emotional condition; and
when the negotiated service agreement no longer describes the resident’s needs and/or services.
RESIDENT NAME: ___________________________________________________________________
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BH NEGOTIATED SERVICE AGREEMENT
DATE OF ORIGINAL SERVICE AGREEMENT:
TITLE/TYPE
PROVIDER
SIGNATURE
DATE
REVIEW/REVISE DATE
REVIEW/REVISE DATE
RESIDENT
RESIDENT REPRESENTATIVE
RESIDENT REPRESENTATIVE
SURROGATE DECISION MAKER
CASE MANAGER
SOCIAL WORKER
HEALTH PROFESSIONAL
OTHER:
OTHER:
The person signing writes the date s/he actually read and agreed to the plan. If the participant has verbally agreed to the plan, the provider should
note below: (a) the name and role of the participant; (b) the date the participant had the plan to read to them; and (c) what if any changes the
participant recommended for the plan.
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
RESIDENT NAME: ___________________________________________________________________
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