Documentation of the four-form assessment system and AI-powered care plan generation process.
Data collection across medical, functional, environmental, and person-centered domains.
Structured prompt combines all data for comprehensive analysis with pattern recognition.
Tailored deliverables for caregivers, families, clinical partners, and internal teams.
Process Time: Traditional care plans require 2-4 hours of manual synthesis. This system generates 10 documents in approximately 5 minutes by structuring assessments to feed directly into AI analysis.
Four forms capture different dimensions of client needs to create a complete assessment.
Staff-completed form containing PHI
Completed by staff during initial phone contact. Contains all PHI required for agency operations, billing, and emergency response. Generates de-identified client code used in all subsequent forms.
HIPAA Note: This is the only form in the system that contains PHI. Client code generated here is used to link all other assessment forms without exposing identifying information.
De-identified demographic and medical baseline
Establishes baseline care context, scheduling parameters, and home environment. Links to PHI via client code without containing identifying information.
Format: JotForm with demo button for testing
Understanding the person beyond diagnosis
Captures qualitative context for AI pattern recognition. Identifies grief, isolation, medication non-compliance triggers, and behavioral patterns. Informs communication approach and reveals hidden risks.
Format: Optional sections, all fields can be skipped, adapts based on indicated concerns
In-person care evaluation using task code scripts
Assessor follows exact task code scripts, asking one question at a time. For each task: document what happens without help, days/times needed, and level of care (0-4 scale).
Level of Care Scale: 0 = No Help, 1 = Reminders, 2 = Supervision, 3 = Standby Assistance, 4 = Hands-On Assistance
24 Task Categories: Meal prep, housework, finances, medications, shopping, transportation, hygiene, dressing (upper/lower), locomotion, transfers, toilet use, bed mobility, eating, bladder/bowel incontinence, personal care, bathing (wash-up/shower), lotion, laundry, reading/writing, supervision
Generates shift-specific task lists based on Level of Care ratings and scheduling requirements. Identifies fall risks, transfer safety needs, incontinence management, and supervision requirements. Determines caregiver training needs and equipment requirements.
Format: Assessor-administered with structured interview protocol
Home safety evaluation during in-person visit
Generates equipment recommendations (grab bars, shower bench, raised toilet seat, etc.). Informs caregivers of hazards and home-specific safety protocols. Assigns overall home safety risk level (Low/Moderate/High) to influence supervision level and fall prevention strategies.
Format: On-site inspection focusing on path of travel: bedroom → bathroom → kitchen → exit
How the four assessment forms combine into a structured prompt for AI analysis.
Each form has a "Generate AI Summary" button that creates de-identified export with assessment data only.
All four exports combine automatically into a single structured prompt. Demo buttons allow testing with pre-filled data.
Prompt instructs AI to analyze patterns, identify risks, and generate 10 tailored output documents.
Establishes AI role as care planning specialist for non-medical home care serving Medicaid clients in Pennsylvania.
Clearly labeled sections for each assessment form's output.
Client Profile Data
Demographics, care needs, schedule, environment
Person-Centered Data
Medical history, preferences, goals, life story
Functional Assessment Data
24 task categories with level of care ratings
Environmental Data
Home safety evaluation and risk assessment
AI analyzes data across 10 specific dimensions before generating outputs.
Specifies exact formatting and content requirements for each audience-specific document.
Every care plan generates 10 tailored documents designed for different audiences and use cases.
The most important document for direct care staff. Contains everything a caregiver needs to know for each shift.
Printed and provided to every caregiver before their first shift. Reduces orientation time and ensures consistency across all caregivers.
At-a-glance risk summary with color-coded severity ratings for immediate visibility.
🔴 High Risk
Falls, choking, elopement
🟡 Moderate Risk
UTIs, skin breakdown, isolation
🟢 Monitored
Medication changes, diet
AI-identified behavioral and medical patterns that may not be obvious from individual data points.
Risks not explicitly stated but inferred from assessment data — things humans might miss.
Why This Matters: A client might not mention they skip medications due to cost, or that they avoid showering because they're afraid of falling. AI connects dots across all four forms to surface these unspoken concerns.
Person-centered focus on what the client CAN do, wants to maintain, and hopes to achieve.
What They Can Still Do
Maintains abilities to preserve
What They Want to Do
Goals that matter to them
Decision flowchart: if you observe X, then do Y. When to document, when to call office, when to call 911.
How to talk with this specific client: topics they enjoy, things to avoid, preferred communication style.
✅ Conversation Starters
Safe topics that engage them
⚠️ Topics to Avoid
Sensitive subjects or triggers
Traditional care plan format for chart documentation and external provider communication.
Use Case: Required documentation for agency files. Can be shared with case managers, skilled nursing, or other providers who need formal care plan documentation.
Quick reference: what to observe, when to be concerned, medication schedule and side effects to monitor.
Safety equipment recommendations and home-specific considerations for caregivers.
Grab bars, shower bench, walker, raised toilet seat, etc.
Hazards, access instructions, pet considerations
Different audiences need different information. Caregivers need task checklists. Families need reassurance without medical jargon. Administrators need compliance and staffing info. Clinical partners need risk data. One generic care plan can't serve all these needs effectively.
Traditional approach: Write one care plan, spend 2-4
hours, everyone gets the same document.
AI approach: Generate 10 targeted documents in 5
minutes, each optimized for its audience.
Technical documentation of the form chain, code generation, and HIPAA architecture
Staff or client fills out. Contains real name, address, SSN, etc.
Staff generates unique client code using external tool (e.g., "Gentle Sparrow")
Staff sends unique URL:
form2.com?code=GentleSparrow
Client clicks link → code auto-populated in hidden field → client fills out form
After Step 2 submits → auto-redirect to
survey.com?code=GentleSparrow
Code passes through redirect URL → hidden field captures it → client continues
Staff completes during in-person visit → manually enters client code
Staff completes during in-person visit → manually enters client code
Key Security Feature: The only link between real identity and client code exists on physical paper in a locked cabinet. No digital connection exists between PHI and assessment data.
Forms 2 & 3 use URL parameter passing:
?code=ClientCode
in redirect URLs. JotForm hidden fields capture the parameter
automatically.
Since forms are long, enable JotForm's "Save & Continue Later" feature. Clients get a unique link to resume their progress if they take a break.
Use external random name generator or manual assignment. Code must be generated OUTSIDE the PHI form to maintain separation. Staff creates physical log entry before sending Form 2 link.
The code system adds complexity that may not be necessary for very small agencies. Alternative: use HIPAA JotForm for all forms and skip the code architecture entirely. The prefill approach is more elegant but requires the PHI/de-identification split.