* = Required Information
Employee Name
*
Week Ending Date
Client Name
*
Client Signature
*
BATH
Complete/Partial
S
M
T
W
T
F
S
Shower
S
M
T
W
T
F
S
Tub
S
M
T
W
T
F
S
PERINEAL CARE
Assist To Bathroom
S
M
T
W
T
F
S
Assist To Commode
S
M
T
W
T
F
S
SKIN CARE
Lotion
S
M
T
W
T
F
S
Massage
S
M
T
W
T
F
S
Shave
S
M
T
W
T
F
S
Nails
S
M
T
W
T
F
S
ORAL CARE
Teeth
S
M
T
W
T
F
S
Dentures
S
M
T
W
T
F
S
FOOT CARE
Lotion
S
M
T
W
T
F
S
Soaks/Elastic Hose
S
M
T
W
T
F
S
HAIR CARE
Shampoo
S
M
T
W
T
F
S
Comb, Brush
S
M
T
W
T
F
S
DRESS
Assist
S
M
T
W
T
F
S
Self
S
M
T
W
T
F
S
TRANSFERS
Bed to W/C
S
M
T
W
T
F
S
W/C to Bed
S
M
T
W
T
F
S
Reposition
S
M
T
W
T
F
S
HOMEMAKING
Laundry
S
M
T
W
T
F
S
Shopping
S
M
T
W
T
F
S
Kitchen
S
M
T
W
T
F
S
Bathroom
S
M
T
W
T
F
S
Bedroom/Linens
S
M
T
W
T
F
S
Living Room
S
M
T
W
T
F
S
Trash
S
M
T
W
T
F
S
NUTRITIONS
Prepare Meal
S
M
T
W
T
F
S
Feeding
S
M
T
W
T
F
S
Assist Feeding
S
M
T
W
T
F
S
COMPANION
Companion
S
M
T
W
T
F
S
SOCIALIZE
Socialize
S
M
T
W
T
F
S
SAFETY
Safety
S
M
T
W
T
F
S
RESTRICTIONS
Restrictions
S
M
T
W
T
F
S
Signature
*
Date
Submit