TIME SHEET
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FAX 1888 681 9011 OR EMAIL office@IN-hhc.com. THIS FORM MUST BE FAXED OR EMAIL IN BY THE END OF THE DAY ON THE 1st,8th, 16th & 22nd Please note: Your paycheck will be delayed if your time sheet is not received by the above dates.
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| RN/P-O-ST/LPN/HHA NAME |
SUE DANKO |
Pay Period ended: |
15th or 30th /31st |
| RN/P-O-ST/LPN/HHA NAME SIGNATURE: |
SUE DANKO
In signing I am certifying that I have personally completed this timesheet and the hours are accurate. |
| PATIENT NAME: |
Julie Moore |
Signature |
Julie moore |
Date 3/15/16 |
| Day - Date |
Type |
Start Time |
End Time |
Total Hrs. |
Odometer Started |
Odometer Ended |
Total Mileage |
Patient’s Initial |
| MON 3/2 |
PA |
9:00AM |
11:00AM |
2 |
9874 |
9876 |
2 |
J |
| MOM 3/2 |
MARE |
11:00AM |
12:00PM |
1 |
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J |
| MON 3/2 |
ATTN |
12:00PM |
2:00PM |
2 |
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J |
| WED 3/4 |
PA |
9:00AM |
4:00PM |
7 |
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J |
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TOTAL |
12 |
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2 |
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| Day - Date |
Type |
Start Time |
End Time |
Total Hrs. |
Odometer Started |
Odometer Ended |
Total Mileage |
Patient’s Initial |
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Please Totals Hours/Mileage |
12 |
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2 |
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VISITING NOTE
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OFFICE USE ONLY
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| DAY |
MARE |
ATTN |
HKM |
PA |
CHOICE |
PVT |
INSU |
RES |
VA |
SSBG |
T3 |
T3E |
VHSP |
| MON |
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| TUES |
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| WED |
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| THUR |
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| FRI |
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| SAT |
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| SUN |
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| DAY |
DATE |
TIME IN |
TIME OUT |
TOTAL HOURS |
TYPE1 |
TYPE2 |
TYPE3 |
PT INITIAL |
STAFF INITIAL |
| MON |
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| TUES |
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| WED |
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| THUR |
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| FRI |
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| SAT |
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| SUN |
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| DESCRIPTION |
M |
T |
W |
TH |
F |
SA |
SU |
DESCRIPTION |
M |
T |
W |
TH |
F |
SA |
SU |
| TUB/SHOWER ASSIST |
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REPOSITION BED/CHAIR PATIENT |
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| BATHROOM CLEAN UP |
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MEDICATION REMINDERS |
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| PERINEAL CARE |
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ASSIST TO BR, BSC, BED PAN |
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| SKIN CARE/LOTION |
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CATH CARE, FOLEY/EXT |
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| ORAL CARE/SHAVE |
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INCONTINENT CARE |
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| SHAMPOO/COMB |
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PREP OF MEALS/SNACKS |
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| SAFETY PROCAUTIONS |
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|
ERRANDS |
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| NAILS CLEAN/FILE |
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KITCEN CLEAN UP |
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| DRESS/UNDRESS |
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BED MADE/ LINEN CHANGE |
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| ASSIST WITH AMBULATION |
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CLIENT LAUNDRY DONE |
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| RANGE OF MOTION |
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MAINT. CLEAN EQUIP |
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| TRANSFER ASSIST |
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VACCUM/DUSTING |
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A |
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& |
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D |
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O |
N |
L |
Y |
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| MECHANICAL LIFT |
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OSTOMY CARE |
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| OTHER |
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RECORD INTAKE/OUTPUT |
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| ASSIST FEEDING |
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CHECK/ REINFORCE DRESSING |
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