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Caregiver Notes
Kathy Faenzi and JC Spicer
2023-11-29T22:23:42+00:00
Caregiver Notes
Caregiver notes to clients.
Client Information
Client
(Required)
Select One
Shirley Massoglia
Chose Client from Dropdown
Date
(Required)
MM slash DD slash YYYY
Caregiver Name
(Required)
Shift Time
(Required)
Client Vitals
Please fill in all that apply
Weight (lbs)
Blood Pressure
example: 120/80
Temperature
Body Temperature (Degrees)
Pulse Rate
Medication Reminders
Please Select
Independent
Reminders
Other
If Other
If other please explain
Memory Loss
Please Select
Unchanged
Agitated
Combative
Sundowners
***Changed***
If Changed
If changed please explain
Mood Behavior
Select One
Unchanged
***Changed***
If Changed
If changed please explain
Transfers / Ambulation
Check all that apply
Independent
Unchanged
***Changed***
Sit to stand assist
Full Transfer
Two person transfer
Hoyer Lift
If Changed
If changed please explain
Number of falls
Add a number for falls
Other
Other examples
Bathing
Check all that apply
Independent
Unchanged
***Changed***
Stand by assist
Shower assist
Sponge/bed bath
Hoyer Lift
If Changed
If changed please explain
Bed Sore
Please explain bed sore
Other bathing
Please explain other bathing
Toileting
Check all that apply
Independent
Unchanged
***Changed***
Assist to and from
Brief Change
Personal care
If Changed
If changed please explain
Other toileting
Please explain other toileting
Dressing
Check all that apply
Independent
Unchanged
***Changed***
Stand by assist
100% Assistance
Set up clothes
If Changed
If changed please explain
Meal Prep
Check all that apply
Independent
Unchanged
***Changed***
Puree
Cut food into small pieces
Thickened Fluids
Feeding assistance
If Changed
If changed please explain
Food Intake
Breakfast %
Lunch %
Dinner %
Snacks %
Other %
If Changed
If changed please explain
Fluid Intake
Number of glasses
Fluids
Example: Milk, Water, Ensure
Urine Output
Number of urinations
Check all that apply
Oder / smell
Discoloration
***Changed***
Burning sensation
Unchanged
Thickened Fluids
If Changed
If changed please explain
Other urine
Please explain other urine output
Bowel Movement
Number of movements
Check all that apply
Normal
Hard to pass
***Changed***
Loose stool
If Changed
If changed please explain
Housekeeping
Only 20% of full shift should be focused on client related housekeeping.
Describe housekeeping
Daily Shift
Are you taking your 3 - 40 minute breaks?
YES
NO, CALL OFFICE TO REPORT
Are you getting 8 hours uninterrupted sleep at night?
YES
NO, CALL OFFICE TO REPORT
I've practised universal precautions?
YES
NO, CALL OFFICE TO REPORT
Gloves, Masks, and hand washing
Have You Checked CHANGED?
If you have checked off "Changed" you MUST call the office immediately
Observations / Activities with Client:
Caregiver Signature
Date
MM slash DD slash YYYY
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