Hospice Caregiver Daily Documentation Form
Client Name
*
Date
*
/
Month
/
Day
Year
Date
Caregiver Name
*
Shift Time In
*
Shift Time Out
*
Care Provided
Bathing/Bed Bath
Yes
No
Notes
Oral Care
Yes
No
Notes
Incontinence Care
Yes
No
Notes
Repositioned (every 2 hours)
Yes
No
Notes
Grooming (Hair, Nails)
Yes
No
Notes
Skin Check (Redness, Sores)
Yes
No
Notes
Medication Reminders (if applicable)
Yes
No
Notes
Meals/Feeding Assistance
Yes
No
Amount Eaten
Notes
Fluids Offered
Yes
No
Amount Drank
Notes
Vital Signs Taken
Yes
No
Notes
Client Observations
Temperature
BP
HR
Pail Level (0-10)
Skin Condition
Appetite
Normal
Poor
None
Mobility
Usual
Slower
Unable
Speech/Alertness
Alert
Confused
Unresponsive
Breathing
Normal
Labored
Irregular
Mood/Behavior
Calm
Anxious
Agitated
Sleeping most of shift
Communication with Hospice Nurse / Agency
Notified Regarding:
Pain or Discomfort
Breathing Changes
Skin Breakdown
Change in Mental Status
Decreased Intake
Family Concerns
Other
Time of Notification
Name of Person Notified
Additional Notes
Caregiver Signature
*
Caregiver Name
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