VISITING NOTE

VISITING NOTE PATIENT NAME: Julie Moore EMPLOYEE NAME: Sue Danko BRANCH Richmond 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 3/2 3/2 9:00am 11:00am 11:00am 1:00pm 2 3 HMK ATTN J S TUES WED 3/9 3:00PM 6:00PM 3 ATTN THUR FRI SAT SUN

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

WEEKLY HOURS:

8

DESCRIPTION

M

T

W

TH

F

SA

SU

DESCRIPTION

M

T

W

TH

F

SA

SU

TUB/SHOWER ASSIST

X

REPOSITION BED/CHAIR PATIENT

BATHROOM CLEAN UP

X

MEDICATION REMINDERS

PERINEAL CARE

x

ASSIST TO BR, BSC, BED PAN

SKIN CARE/LOTION

x

CATH CARE,FOLEY/EXT

ORAL CARE/SHAVE

X

x

INCONTINENT CARE

SHAMPOO/COMB

X

x

PREP OF MEALS/SNACKS

X

SAFETY PROCAUTIONS

KITCEN CLEAN UP

X

DRESS/UNDRESS

X

x

BED MADE/ LINEN CHANGE

ASSIST WITH AMBULATION

X

CLIENT LAUNDRY DONE

X

RANGE OF MOTION

X

MAINT. CLEAN EQUIP

TRANSFER ASSIST

VACCUM/DUSTING

X

A

&

D

O

N

L

Y

MECHANICAL LIFT

OSTOMY CARE

OTHER

RECORD INTAKE/OUTPUT

ASSIST FEEDING

CHECK/ REINFORCE DRESSING

EMPLOYEE SIGNATURE:	Sue Danko
PATIENT SIGNATURE	Juie Moore
POA