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HOME HEALTH AIDE DUTY SHEET
CAREGIVER INFORMATION
Caregiver Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Caregiver ID
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PATIENT INFORMATION
Patient Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
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VISIT INFORMATION - CLOCK IN / CLOCK OUT
Clock In Date
*
 -
Month
 -
Day
Year
Date
In Time
*
Hour Minutes
AM
PM
AM/PM Option
Clock Out Date
*
 -
Month
 -
Day
Year
Date
NOTE: [Clock Out Date] must be the same or greater than [Clock In Date] before continuing.
Out Time
*
Hour Minutes
AM
PM
AM/PM Option
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PLAN OF CARE DUTIES
BATH IN TUB
*
Y
N
BATH IN SHOWER
*
Y
N
BED BATH
*
Y
N
HAIR CARE-SHAMPOO
*
Y
N
GROOMING-SHAVE
*
Y
N
HAIR CARE-COMB
*
Y
N
MOUTH CARE/DENTURE CARE
*
Y
N
APPLY LOTION
*
Y
N
GROOMING-NAILS
*
Y
N
DRESS PATIENT
*
Y
N
TOILETING-BEDPAN/URINAL
*
Y
N
INCONTINENCE CARE
*
Y
N
TOILETING-DIAPER
*
Y
N
TOILETING-COMMODE
*
Y
N
TOILETING-TOILET
*
Y
N
EMPTY FOLEY BAG
*
Y
N
RECORD INTAKE-FOOD AND FLUID
*
Y
N
RECORD OUTPUT (URINE/BM)
*
Y
N
DO PATIENT GROCERY SHOPPING
*
Y
N
MEAL PREPARATION
*
Y
N
ESCORT TO MEALS
*
Y
N
SERVE/ SETUP
*
Y
N
ASSIST WITH FEEDING
*
Y
N
WEIGH PATIENT
*
Y
N
ASSIST WITH EQUIPMENT
*
Y
N
CHAIR TRANSFER
*
Y
N
BED TRANSFER
*
Y
N
BATHROOM TRANSFER
*
Y
N
WHEELCHAIR TRANSFER
*
Y
N
ASSIST WITH WALKING
*
Y
N
TURNING AND POSITIONING (AT LEAST Q2)
*
Y
N
SKIN CARE
*
Y
N
ACTIVE ROM
*
Y
N
PASSIVE ROM
*
Y
N
ASSIST WITH HOME EXERCISE PROGRAM
*
Y
N
TAKE TEMPERATURE
*
Y
N
TAKE PULSE
*
Y
N
TAKE BLOOD PRESSURE
*
Y
N
REMIND TO TAKE MEDICATION
*
Y
N
DO PATIENT ERRANDS
*
Y
N
MAKE/CHANGE BED
*
Y
N
PATIENT INCONTINENT / CHANGE BED
*
Y
N
VACUUM
*
Y
N
DUST
*
Y
N
PATIENT LAUNDRY
*
Y
N
CLEAN BATHROOM
*
Y
N
CLEAN KITCHEN
*
Y
N
SHOWER WITH CHAIR
*
Y
N
ESCORT PATIENT TO MEDICAL APPOINTMENT IF NEEDED
*
Y
N
TAKE RESPIRATIONS
*
Y
N
DIABETIC FOOT CARE
*
Y
N
ESCORT TO MEDICATION ROOM
*
Y
N
GLUCOSE TESTING
*
Y
N
ADMINISTRATION OF INSULIN
*
Y
N
SET UP AND ADMINISTER NEBULIZER TREATMENT
*
Y
N
ADMINISTER EAR DROPS
*
Y
N
ADMINISTER EYE DROPS
*
Y
N
REFUSED SOME PERSONAL CARE TASKS
*
Y
N
REFUSED ALL PERSONAL CARE TASKS
*
Y
N
PATIENT REQUIRES TOTAL CARE
*
Y
N
PATIENT IS ON PRESCRIBED DIET
*
Y
N
PREPARE-BREAKFAST
*
Y
N
PREPARE-LUNCH
*
Y
N
PREPARE SNACK
*
Y
N
PREPARE-DINNER
*
Y
N
RECORD INTAKE - FOOD
*
Y
N
RECORD INTAKE - FLUID
*
Y
N
TRANSFERRING
*
Y
N
PATIENT WALKS WITH ASSISTIVE DEVICES
*
Y
N
RANGE OF MOTION EXERCISES
*
Y
N
ASSIST WITH CATHETER CARE
*
Y
N
ASSIST WITH OSTOMY CARE
*
Y
N
EMPTY FOLEY BAG
*
Y
N
ASSIST WITH TREATMENT
*
Y
N
LIGHT HOUSEKEEPING
*
Y
N
CLEAN PATIENT CARE EQUIPMENT
*
Y
N
DIVERSIONAL ACTIVITIES-SPEAK/READ
*
Y
N
MONITOR PATIENT SAFETY
*
Y
N
DIET-REGULAR
*
Y
N
DIET-LOW SALT/NO ADDED SALT
*
Y
N
DIET-2GM SODIUM
*
Y
N
DIET-LOW FAT
*
Y
N
DIET-LOW CHOLESTEROL
*
Y
N
DIET-NO CONCENTRATED SWEETS
*
Y
N
DIET-ADA CALORIES
*
Y
N
DIET-RENAL
*
Y
N
DIET-FLUID RESTRICTION
*
Y
N
DIET-OTHER
*
Y
N
FALL PRECAUTIONS
*
Y
N
SEIZURE PRECAUTIONS
*
Y
N
BLEEDING PRECAUTIONS
*
Y
N
STANDARD PRECAUTIONS
*
Y
N
OXYGEN SAFETY PRECAUTIONS
*
Y
N
OBSERVATION OF SKIN CONDITION
*
Y
N
Duty Count
NOTE: You must choose at least 5 duties that were performed before continuing.
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PATIENT REVIEW
Start Date:
Start Time:
End Date:
End Time:
PATIENT SIGNATURE
Signature
*
Patient unable to sign
Please select one
Patient is blind
Patient disabled
Aid no longer works with patient
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CONFIRMATION
VISIT INFORMATION
Caregiver Name:
Caregiver Phone:
Patient Name:
Patient Phone:
Admission Id:
CLOCK IN / CLOCK OUT
Clock In Date:
In Time:
Clock Out Date:
Out Time:
DUTY PERFORMED
BATH IN TUB
*
Y
N
BATH IN SHOWER
*
Y
N
BED BATH
*
Y
N
HAIR CARE-SHAMPOO
*
Y
N
GROOMING-SHAVE
*
Y
N
HAIR CARE-COMB
*
Y
N
MOUTH CARE/DENTURE CARE
*
Y
N
APPLY LOTION
*
Y
N
GROOMING-NAILS
*
Y
N
DRESS PATIENT
*
Y
N
TOILETING-BEDPAN/URINAL
*
Y
N
INCONTINENCE CARE
*
Y
N
TOILETING-DIAPER
*
Y
N
TOILETING-COMMODE
*
Y
N
TOILETING-TOILET
*
Y
N
EMPTY FOLEY BAG
*
Y
N
RECORD INTAKE-FOOD AND FLUID
*
Y
N
RECORD OUTPUT (URINE/BM)
*
Y
N
DO PATIENT GROCERY SHOPPING
*
Y
N
MEAL PREPARATION
*
Y
N
ESCORT TO MEALS
*
Y
N
SERVE/ SETUP
*
Y
N
ASSIST WITH FEEDING
*
Y
N
WEIGH PATIENT
*
Y
N
ASSIST WITH EQUIPMENT
*
Y
N
CHAIR TRANSFER
*
Y
N
BED TRANSFER
*
Y
N
BATHROOM TRANSFER
*
Y
N
WHEELCHAIR TRANSFER
*
Y
N
ASSIST WITH WALKING
*
Y
N
TURNING AND POSITIONING (AT LEAST Q2)
*
Y
N
SKIN CARE
*
Y
N
ACTIVE ROM
*
Y
N
PASSIVE ROM
*
Y
N
ASSIST WITH HOME EXERCISE PROGRAM
*
Y
N
TAKE TEMPERATURE
*
Y
N
TAKE PULSE
*
Y
N
TAKE BLOOD PRESSURE
*
Y
N
REMIND TO TAKE MEDICATION
*
Y
N
DO PATIENT ERRANDS
*
Y
N
MAKE/CHANGE BED
*
Y
N
PATIENT INCONTINENT / CHANGE BED
*
Y
N
VACUUM
*
Y
N
DUST
*
Y
N
PATIENT LAUNDRY
*
Y
N
CLEAN BATHROOM
*
Y
N
CLEAN KITCHEN
*
Y
N
SHOWER WITH CHAIR
*
Y
N
ESCORT PATIENT TO MEDICAL APPOINTMENT IF NEEDED
*
Y
N
TAKE RESPIRATIONS
*
Y
N
DIABETIC FOOT CARE
*
Y
N
ESCORT TO MEDICATION ROOM
*
Y
N
GLUCOSE TESTING
*
Y
N
ADMINISTRATION OF INSULIN
*
Y
N
SET UP AND ADMINISTER NEBULIZER TREATMENT
*
Y
N
ADMINISTER EAR DROPS
*
Y
N
ADMINISTER EYE DROPS
*
Y
N
REFUSED SOME PERSONAL CARE TASKS
*
Y
N
REFUSED ALL PERSONAL CARE TASKS
*
Y
N
PATIENT REQUIRES TOTAL CARE
*
Y
N
PATIENT IS ON PRESCRIBED DIET
*
Y
N
PREPARE-BREAKFAST
*
Y
N
PREPARE-LUNCH
*
Y
N
PREPARE SNACK
*
Y
N
PREPARE-DINNER
*
Y
N
RECORD INTAKE - FOOD
*
Y
N
RECORD INTAKE - FLUID
*
Y
N
TRANSFERRING
*
Y
N
PATIENT WALKS WITH ASSISTIVE DEVICES
*
Y
N
RANGE OF MOTION EXERCISES
*
Y
N
ASSIST WITH CATHETER CARE
*
Y
N
ASSIST WITH OSTOMY CARE
*
Y
N
ASSIST WITH TREATMENT
*
Y
N
LIGHT HOUSEKEEPING
*
Y
N
CLEAN PATIENT CARE EQUIPMENT
*
Y
N
DIVERSIONAL ACTIVITIES-SPEAK/READ
*
Y
N
MONITOR PATIENT SAFETY
*
Y
N
DIET-REGULAR
*
Y
N
DIET-LOW SALT/NO ADDED SALT
*
Y
N
DIET-2GM SODIUM
*
Y
N
DIET-LOW FAT
*
Y
N
DIET-LOW CHOLESTEROL
*
Y
N
DIET-NO CONCENTRATED SWEETS
*
Y
N
DIET-ADA CALORIES
*
Y
N
DIET-RENAL
*
Y
N
DIET-FLUID RESTRICTION
*
Y
N
DIET-OTHER
*
Y
N
FALL PRECAUTIONS
*
Y
N
SEIZURE PRECAUTIONS
*
Y
N
BLEEDING PRECAUTIONS
*
Y
N
STANDARD PRECAUTIONS
*
Y
N
OXYGEN SAFETY PRECAUTIONS
*
Y
N
OBSERVATION OF SKIN CONDITION
*
Y
N
Patient unable to sign
Patient is blind
Patient disabled
Aid no longer works with patient
CAREGIVER SIGNATURE
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