| |
DATE |
DATE |
DATE |
DATE |
DATE |
DATE |
DATE |
|
Visit Date |
|
|
|
|
|
|
|
|
Time In |
|
|
|
|
|
|
|
|
Time Out |
|
|
|
|
|
|
|
|
FRI |
SAT |
SUN |
MON |
TUE |
WED |
THR |
|
Body Mech /Mobility |
|
Transfers |
|
|
|
|
|
|
|
|
Ambulation |
|
|
|
|
|
|
|
|
Cane / Walker |
|
|
|
|
|
|
|
|
Prescribed ROM |
|
|
|
|
|
|
|
|
Turning & Positioning |
|
|
|
|
|
|
|
|
Bath |
|
Tub |
|
|
|
|
|
|
|
|
Shower |
|
|
|
|
|
|
|
|
Bed |
|
|
|
|
|
|
|
|
Chair |
|
|
|
|
|
|
|
|
Oral Hygiene |
|
Brush Teeth |
|
|
|
|
|
|
|
|
Clean Dentures |
|
|
|
|
|
|
|
|
Mouth Wash |
|
|
|
|
|
|
|
|
Oral Swabs |
|
|
|
|
|
|
|
|
Hair Care |
|
Comb / Brush |
|
|
|
|
|
|
|
|
Shampoo |
|
|
|
|
|
|
|
|
Skin & Nail
Care |
|
Warm / Dry |
|
|
|
|
|
|
|
|
Diaphoretic |
|
|
|
|
|
|
|
|
Redness / Bruising |
|
|
|
|
|
|
|
|
Apply Lotion |
|
|
|
|
|
|
|
|
Nail Cleaning /Filling |
|
|
|
|
|
|
|
_______________________________________
Employee Signature Date
_______________________________________
Title |
|
| |
FRI |
SAT |
SUN |
MON |
TUE |
WED |
THR |
|
Personal Care |
|
Dressing |
|
|
|
|
|
|
|
|
Shaving |
|
|
|
|
|
|
|
|
Pet Care |
|
|
|
|
|
|
|
|
Elimination |
|
|
|
|
|
|
|
|
Bed Pan |
|
|
|
|
|
|
|
|
Bedside Commode |
|
|
|
|
|
|
|
|
Colostomy Care |
|
|
|
|
|
|
|
|
Catheter Care |
|
|
|
|
|
|
|
|
Assist on Toilet |
|
|
|
|
|
|
|
|
Nutrition |
|
Prepare Meals |
|
|
|
|
|
|
|
|
Serve Meals |
|
|
|
|
|
|
|
|
Assist Feeding |
|
|
|
|
|
|
|
|
Offer Fluids |
|
|
|
|
|
|
|
|
Homemaking / Non-personal
Care |
|
Shopping |
|
|
|
|
|
|
|
|
Errands |
|
|
|
|
|
|
|
|
Transporting |
|
|
|
|
|
|
|
|
Dust |
|
|
|
|
|
|
|
|
Vacuum |
|
|
|
|
|
|
|
|
Straiten |
|
|
|
|
|
|
|
|
Wash Dishes |
|
|
|
|
|
|
|
|
Clean Kitchen |
|
|
|
|
|
|
|
|
Clean Bathroom |
|
|
|
|
|
|
|
|
Make Bed |
|
|
|
|
|
|
|
|
Change Bed |
|
|
|
|
|
|
|
|
Laundry |
|
|
|
|
|
|
|
|
Safety |
| Reminder |
|
|
|
|
|
|
|
|
_______________________________________
Patient Name (PLEASE
PRINT)
Date
_______________________________________
Patient Signature |
|
