Control

A PREMIER HOME PROVIDER SERVICE LLC

Caregiver ID:

Unregistered caregiver

Client Name:

Caregiver name:

ROLE:

Select Day to Fill:

Pursuant to regulations by the Nurse registry for Health care Administration, it is mandatory that Care Provider documents any changes in care services

PERSONAL CARE/ADL ASSISTANCE

BATHING/SHOWER

DRESSING

AMBULATION

TRANSFERRING

RE-POSITIONING

RANGE OF MOTION ASSISTANCE

FEEDING

GROOMING, SHAVING HAIR CARE

APPLY LOTION

ORAL HYGIENE

TOILETING

INCONTINENCE CARE/DIAPER CHANGE

ASSIST WITH OSTOMY CARE

RECORD VITAL SIGNS

RECORD INTAKE/OUTPUT

RECORD WEIGHT

OBSERVE PHYSICAL & MENTAL CHANGES

REMIND PATIENT OF MEDICATIONS

ASSIST PATIENT WITH SELF ADMINISTRATION OF MEDICATION

COMPANIONSHIP

ADL SUPERVISION/STANDBY ASSIST

ACCOMPANY TO APPOINTMENTS

PREPARE MEALS

GROCERY SHOPPING

CHANGE BED LINEN

LAUNDRY

LIGHT HOUSEKEEPING

COSMETIC ASSISTANCE

HOURLY

TIME STARTED

TIME FINISHED

TOTAL HOURS

Caregiver Signature:

Client Signature:

Client Signature

Food

Amount

Time

Comments

Activities

Duration

Time

Comments

Medication

Dose

Time

Comments

Rate the following from 1 to 10 with 1 being the lowest and 10 being the highest.

Pain and Discomfort

Energy Level

Sleep Patterns

Nausea / Constipation

Document additional changes noted. (Use Progress notes as needed)