Impaired Home Maintenance Management

Instructions: Fill out this form, print it, and hand it in with your assessment to your instructor. When you click on Next at the bottom of the page, you see the data you submitted. Please follow the instructions on how to save the data on the next page.

AOL users: Read this instruction.

Definition: inability to independently maintain a safe, growth promoting environment

1. Your initials (required): 

2. Defining Characteristics- check those that apply to your client:

None- high risk diagnosis  states difficulty in maintaining home (cleaning, repairs, financial needs) poor hygenic practices  overtaxed family members  offensive odors  lack of necessary equipment or aids  unwashed cooking utensils

3. Related Factors- check those that apply to your client:

impaired cognitive or emotional functioning  inadequate support system    ill family member(s)  ineffective organization, time management  insufficient finances  maturational (newborn care) maturational (elderly family member with deficits)


4. Goal (ultimate, long term) 

5. Outcome Criteria (short term) 

6. Evaluation: Was the outcome criteria met? 

Yes- Give Evidence: 

No- Explain how you would change the plan: 

7A. Interventions 

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7B. Rationale for each intervention

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