Daily Care Notes
Client Name:
Date:
-
Month
-
Day
Year
Date
Caregiver Name:
Shift Time: From
Hour Minutes
AM
PM
AM/PM Option
To
Hour Minutes
AM
PM
AM/PM Option
1. Activities of Daily Living (ADLs)
Rows
Performed (Yes)
Notes (No)
Bathing/Showering
Grooming/Shaving
Oral Care
Dressing
Toileting/Incontinence Care
Ambulation/Transfers
Meal Prep & Feeding
Medication Reminders Given
Light Housekeeping
2. Observations & Behaviors
General mood
Good
Fair
Poor
Appetite:
Normal
Decreased
Increased
Sleep quality:
Good
Fair
Poor
Skin condition:
Normal
Redness
Breakdown
Any concerns or incidents:
3. Client Comments/Requests
4. Caregiver Notes
Caregiver Signature:
Date:
-
Month
-
Day
Year
Date
Client Signature:
Date:
-
Month
-
Day
Year
Date
Please explain reason why notes & signature was documented
If you are unable to clock in or out and call the office for assistance, you must provide the name of the person who clocked you in/out and the exact start and end times of your shift.
Name
Clock In/Out
Submit
Should be Empty: