Home Health/Private Duty Timesheet

Home Health & Private Duty Timesheet
Please submit only NON-LICENSED Home Health or Private Duty shift timesheets via this form.

Licensed staff must use paper timesheets for Home Health or Private Duty shifts.

For shifts at facilities, submit your timesheets here: FACILITY TIMESHEETS
Employee Information
Employee Name*

First NameLast Name
Employee Email
(Optional) To receive a copy of your timesheet submission, please enter your email address.
Shift Details

The fields below should be completed by the CareStaf employee.
Client Name*
First Name
Last Name
Patient Security ID
Shift Start Date*

MonthDayYear
Date
Shift End Date*

MonthDayYear
Date
Shift Times*

Clock-in Time

AM/PM Option

Until
until
Clock-out Time

AM/PM Option
Total 0.0
Daily or Instant Pay*

YesNo
Care Details

The fields below should be completed by the CareStaf employee, if conducted during shift.
(1) Meals prepared, administered, and clean-up completed?*

YesNoDeclined
Specify details:
(2) Any swallowing problems? Such as gagging, retching, or emesis.

YesNo
Specify details:
Caregiver, nurse, or facility staff notified?

YesNo
(3) Specify percentage of meal eaten:
Format: [B __%] [L __%] [D __%]
Specify food administered:
(4) Sip of water, favorite drink, or ice chips offered?*

YesNoDeclined
Specify drink administered:
(5) Oral medication reminder completed?*

YesNoDeclined
Specify details:
(6) Has the patient reported any unrelieved pain?*

YesNo
Specify details:
Caregiver, nurse, or facility staff notified?

YesNo
(7) Was hearing aid and/or batteries inserted/removed?*

YesNoDeclined
Specify details:
(8) Was any toileting assistance provided?*

YesNoDeclined
Specify details:
(9) Was any ostomy/catheter assistance provided?*

YesNoDeclined
Specify details:
(10) Is bowel movement documentation required by care plan and/or requested by facility staff?*

YesNo
Document bowel movements:
(11) Was oral care conducted?*

YesNoDeclined
Specify details:
(12) Was bathing conducted?*

YesNoDeclined
Where was bathing conducted?

Bed bathTub/ShowerOther
Shaving conducted? Select all that apply.

FaceLegsUnderarmsNone
Specify any notes:
(13) Any grooming conducted?*

YesNoDeclined
Select all hygienic/cosmetic items applied.

Applied lotionsDeodorantColognePowderMakeupNoneOther
(14) Hair and/or nail care conducted?

Hair brushedNails groomedNails polishedNoOther
Specify details:
(15) Was any assistance with dressing and/or undressing conducted?*

YesNoDeclined
Specify details:
(16) Was T.E.D. hose applied and/or removed?*

YesNoDeclined
Lower extremities elevated?*

YesNoDeclined
Specify details:
(17) Was bathroom area cleaned?*

YesNo
Specify details:
(18) Was bed made and/or bedding changed?*

YesNoDeclined
Specify details:
(22) Any changes in mental status?*

YesNo
Specify details:
Caregiver, nurse, or facility staff notified?

YesNo
Did the client become agitated or require redirection?*

YesNo
Specify details:
(23) Any changes in breathing?*

YesNo
Specify details:
Caregiver, nurse, or facility staff notified?

YesNo
(27) Was any assistance with ambulation conducted?*

YesNoDeclined
Specify details:
(28) Was a transfer/gait belt and/or Hoyer Lift used?*

YesNoDeclined
Specify details:
(29) Was patient turned every two hours?*

YesNoDeclined
Was PROM performed?*

YesNoDeclined
Specify details:
(30) Was an incontinence check or brief change completed?*

YesNoDeclined
Specify details:
Special instruction comments:
By signing and submitting, I, {employeeName}, certify that the hours and details for the shift entered above represent my total hours worked and that they were properly verified by an authorized representative of the client or facility.
Employee Signature*

Clear
Client Approval

The fields below should be completed by an authorized representative of the client ONLY.
Authorized Representative Name*

First NameLast Name
Authorized Representative Email*
example@example.com
The signature below of an authorized representative of the client or facility is intended to certify that the hours and details for the shift above are correct and approved, including any changes to the shift as originally scheduled. The client agrees to be bound by the terms of the most recently executive staffing agreement.
Authorized Representative Signature*

Clear
Should be Empty:

Home Health & Private Duty Timesheet

Employee Information

Shift Details

Care Details

Client Approval