Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
DATE
TIME IN
TIME OUT
SUNDAY
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
TOTAL:
# OF HOURS
PATIENT/GUARDIAN SIGNATURE
EMPLOYEE SIGNATURE
WEEK OF:
/
/
THROUGH
/
/
OFFICE USE ONLY:
PAYROLL
Services
SUN
Oral Hygiene/Dentures
Personal services
Bath:Bed/Shower/Tub/tubside
Perineal Care
Shampoo
Comb/Brush Hair
Clean/File Nails
Dress: Bed/Street Cloths
Shave:Razor/Electric
Foot Care
Skin Care: Lotion/Powder/Other
Elimination
BedPan/Urinal
Commode
Catheter Care: Foley/External
Nutrition
Additional Comments:
MON
TUES
WED
Services
SUN
MON
Bathroom
Toilet Care
Bedroom
Ironing
Laundry
Change Linen/Make Bed
Kitchen
Dishes
Grocery
Refridgerator
Sweep
Wet Mop
Living Room
Dusting
Vaccum
Trash
ROM
SAT
Mobility
FRI
Treatment
THUR
Temperature
Pulse
Respirations
Medication reminder
Other:
amba
TUES
WED
THUR
FRI
SAT
DATE
PERSONAL CARE SERVICES AS STATED ON THE ISP
Oral Hygiene (0-5 x week) 5-10 Min
Personal services
Nutrition
Staf
Units
Transportation
SUN
MON
Units
Group Size:
Notes (please note mileage):
TUES
WED
THUR
FRI
SAT
Date(s) of Service:
Client Name: Alexander "Alex" Smith
DODD # : 109636712199
Place of Service:
5685 Elmgee
Delaware, OH 43015
Parent/Legal Guardian Signature
DATE
PERSONAL CARE SERVICES AS STATED ON THE ISP
Personal services
Units
Staf
SUN
MON
TUES
WED
THUR
FRI
SAT
Date(s) of Service:
Client Name: Stephen Masters
DODD # : 108456060499
Place of Service: 14728 Cleveland Rd.SW, Pataskala, OH
43062
Date(s) of Service:
Client Name: MICHAEL PARRECO
DODD # : 106675314499
Place of Service: 6363 Liberty Road N., Powell, OH 43065
DATE
PERSONAL CARE SERVICES AS STATED ON THE ISP
Oral Hygiene (0-5 x week) 5-10 Min
Personal services
Nutrition
Units
TransportationStaf
Grocery Shop
Time in/out: Harold Mintsop
Time in/out:
Starting Odometer Reading
End Odometer Reading
Total Mileage
Total Number of Hours:
Total Number of Units:
Group Size:
Notes (please note mileage):
SUN
MON
TUES
WED
THUR
FRI
SAT
Date(s) of Service:
Client Name: WESLEY PARRECO
DODD # : 106328316099
Place of Service: 6363 Liberty Road N., Powell, OH 43065
DATE
PERSONAL CARE SERVICES AS STATED ON THE ISP
Oral Hygiene (0-5 x week) 5-10 Min
Personal services
Nutrition
Units
TransportationStaf
Grocery Shop
Time in/out: Alexis Yontz
Time in/out:
Starting Odometer Reading
End Odometer Reading
Total Mileage
Total Number of Hours:
Total Number of Units:
Group Size:
Notes (please note mileage):
SUN
MON
TUES
WED
THUR
FRI
SAT
DATE
PERSONAL CARE SERVICES AS STATED ON THE ISP
Oral Hygiene (0-7 x week) 5-10 Min
Nutrition
Units
TransportationStaf
Grocery Shop
Time in/out: Antoinette Kamba
Time in/out:
Starting Odometer Reading
End Odometer Reading
Total Mileage
Total Number of Hours:
Total Number of Units:
Group Size:
Notes (please note additional information):
SUN
MON
TUES
WED
THUR
FRI
SAT
Date(s) of Service:
Client Name: Madison Conley
DODD # : 106248777099
Place of Service:
168 Troy Rd.
Delaware, OH 43015
Parent/Legal Guardian Signature