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info@signalhg.com
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VISITING NOTE
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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