TIME SHEET

TIME SHEET

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.

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 J
MON 3/2 ATTN 12:00PM 2:00PM 2 J
WED 3/4 PA 9:00AM 4:00PM 7 J
TOTAL 12 2
Day - Date Type Start Time End Time Total Hrs. Odometer Started Odometer Ended Total Mileage Patient’s Initial
Please Totals Hours/Mileage 12 2
VISITING NOTE



OFFICE USE ONLY
DAY MARE ATTN HKM PA CHOICE PVT INSU RES VA SSBG T3 T3E VHSP
MON
TUES
WED
THUR
FRI
SAT
SUN
DAY DATE TIME IN TIME OUT TOTAL HOURS TYPE1 TYPE2 TYPE3 PT INITIAL STAFF INITIAL
MON
TUES
WED
THUR
FRI
SAT
SUN

TYPES: ATTN/HMK/CHOICE/PA/RES/MEDICARE/T3/T3E/SSBG/CHSP/INSUR


DESCRIPTION M T W TH F SA SU DESCRIPTION M T W TH F SA SU
TUB/SHOWER ASSIST REPOSITION BED/CHAIR PATIENT
BATHROOM CLEAN UP MEDICATION REMINDERS
PERINEAL CARE ASSIST TO BR, BSC, BED PAN
SKIN CARE/LOTION CATH CARE, FOLEY/EXT
ORAL CARE/SHAVE INCONTINENT CARE
SHAMPOO/COMB PREP OF MEALS/SNACKS
SAFETY PROCAUTIONS ERRANDS
NAILS CLEAN/FILE KITCEN CLEAN UP
DRESS/UNDRESS BED MADE/ LINEN CHANGE
ASSIST WITH AMBULATION CLIENT LAUNDRY DONE
RANGE OF MOTION MAINT. CLEAN EQUIP
TRANSFER ASSIST VACCUM/DUSTING
A & D O N L Y
MECHANICAL LIFT OSTOMY CARE
OTHER RECORD INTAKE/OUTPUT
ASSIST FEEDING CHECK/ REINFORCE DRESSING