• AFC Caregiver Log

    AFC Caregiver Log

  • Note: (If Caregiver is on vacation, Alternate Caregiver provides care, checks "YES", fills, signs and submits form, and gets paid for this period!)

  • AFC FLOW SHEET

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  • Behavior

    1 - Wandering 2 - Verbally Abusive Behavior 3 - Physically Abusive Behavior 4 - Socially Inappropriate Behavior

  • Intervention

    1 - 1:1 2 - Snack 3 - Redirection 4 - Diversion activity (per Care Plan)

  • Outcome

    1 - No Change 2 - Improved 3 - Worsened

  • Daily Behavior Intervention

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  • Caregiver/Alternate Cg Initials

  • Caregiver/Alternate Initials

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    • Description of Activities of Daily Living (ADL)

    • Positioning in Bed or Chair: Turning side to side, changing position while in bed or chair. Transferring: Moving in and out of bed; on/off chair, sofa, etc. (Exclude to/from bath/toilet) Locomotion/Ambulation (in home): Walking/wheeling in the home (if in wheelchair, self-sufficiency once in chair Locomotion/Ambulation (outside): Moving about outside the home (if in wheelchair, self-sufficiency once in chair Dressing upper body: Street clothes on/off from waist up. Includes prostheses and orthotics. Dressing lower body: Street clothes on/off from waist down. Includes prostheses and orthotics.

      Eating: Taking in food by any method, including tube feeding. Bathing: Full body bath/shower or sponge bath (does not include washing of back & hair Personal Hygiene: Shampooing, combing hair, brushing teeth/dentures, shaving, applying makeup, washing & drying of face & hands, washing feet (EXCLUDES bath & showers) Toileting: using toilet, commode, bedpan/urinal, transferring on/off toilet, cleaning self after toilet use, incontinence care, changing pad, managing any special devices required (ostomy or catheter), and adjusting clothes.

    • Description of Instrumental Activities of Daily Living (IADL)

    • Meal Preparation: Planning meals, cooking, assembling ingredients, setting out food and utensils. Ordinary Housework: Doing dishes, dusting, making bed, tidying up, laundry. Managing Finances: Paying bills, balancing checkbook, balancing household expenses. Managing Medications: Reminding to take medications, opening bottles. Phone Use: Making or receiving phone calls (with or without assistive devices, i.e. large numbers on phone, amplification devices

      Shopping: Selecting food and household items, managing money. Transportation: Traveling to places that are beyond walking distances.

    • Description of Behavior Problem

    • Wandering: Moving with no rational purpose seemingly oblivious to needs or safety. Verbally Abusive Behavior: Threatening, screaming or cursing at others.

      Physically Abusive Behavior: Hitting, shoving or scratching. Socially Inappropriate Behavior: Disruptive sounds, noisiness, screaming, self-abusive acts, disrobing in public, smearing or throwing feces, rummaging, repetitive behavior or causing general disruption. Resists Care: Resists assistance with medications, ADL assistance, eating or changes in position. Does not include refusal of care.

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