* = Required Information
Hospice Aide Home Health Aide Homemaker
Monday
VITAL SIGNS
Temperature
BP
Pulse
Respiration
BATH
Tub / Shower
Bed-Partial / Complete
Assist Bath-Chair
Shampoo Hair
Comb Hair
Mouth Care
Shave Electric Straight
Assist with Dressing
HAND / FOOT CARE
Clean / File Nails
Soak Feet
ELIMINATION
Perineal Care
External Cath Care
Measure Cath Output
Empty Drainage Bag
SKIN CARE
Moisture Skin
ACTIVITY
Ambulation / Mobility
Walker / Wheelchair / Cane
Chair / Bed
Dangle / Commode
Exercise-per PT/OT/SLP
Reposition Patient
Other
MEALS
Prepare
Feed
Setup
Offer Oral Supplement
HOUSEKEEPING
Change Bed Linens
Make Bed
Straighten Room
Laundry
Shopping
OTHER
Fall Precautions Maintained