Timesheet / Care Plan
Goals
- Client will not experience any fall
- Client will participant in ADL
- Client will not experience any skin breakdown
SUN
MON
TUES
WED
THU
FRI
SAT
Date
Time In
Time Out
Client Initial
Codes: F=Frequency, R= Refused, U= Unable to Perform, C= Completed, RD=REDIRECT, PR= PROMPT.
FL= Functional Level ( I=Independent, L=limited, E=Extensive)
CARE PLAN
FL
Wkly (F)
Daily (F)
SUN
MON
TUE
WED
THU
FRI
SAT
PERSONAL HYGIENE
Bed / Shower / Sponge Bath
Hair / Skin / Oral Care
FEEDING
Breakfast / Lunch / Diner / PO / Feeder / Cut Food
CLEANING
Bathroom / Kitchen / Dispose trash
Clear pathways
Laundry / Change Linen / Make Bed
Clean Equipment
DRESSING
Shoes / Clothing: on /off
Fold / Hang clothes
Retrieve clothes
Braces/Splints Reinforce Therapy
AIDE TASK
FL
Wkly (F)
Daily (F)
SUN
MON
TUE
WED
THU
FRI
SAT
PRECAUTION
Fall / Seizure
Medication Reminder
TOILETING
BSC / Depends Urinal / Incont.
Accompany to doctor’s office
MOBILITY Light house keeping
Wheelchair
Ambulation
Ambulation with Walker
Turn / ROM Reposition
Transfer to/from bed/chair
DRESSING
Shoes / Clothing: on /off
Fold / Hang clothes
Retrieve clothes
Braces/Splints Reinforce Therapy
I certify that have worked the time shown, and have completed the documented tasks.
I certify that I am satisfied with the services listed above./ Initial Assessment
Timesheet
Label: Your Field Value