Clien Medical Care Log

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CLIENT CARE LOG
Client Name:
_________________________________ Care Provider Name: _____________________________
Role: RN____ LPN____ CNA____ HHA____ Companion_____ Week Ending Date: _____________________________
Pursuant to Regulations by the Agency for Health Care Administration, it is mandatory that Care Provider document any changes in care services.
As per the direction of Client, Care Provider
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
performed the following services:
PERSONAL CARE / ADL ASSISTANCE
BATHING/SHOWER
DRESSING
AMBULATION
TRANSFERRING
RE-POSITIONING
RANGE OF MOTION ASSISTANCE
FEEDING
GROOMING, SHAVING, HAIR CARE
APPLY LOTION
ORAL HYGIENE
TOILETING
INCONTINENCE CARE/DIAPER CHANGE
ASSIST WITH OSTOMY CARE
RECORD VITAL SIGNS
RECORD INTAKE / OUTPUT
RECORD WEIGHT
OBSERVE PHYSICAL & MENTAL CHANGES
REMIND PATIENT OF MEDICATIONS
ASSIST PATIENT WITH SELF-
ADMINISTRATION OF MEDICATION
COMPANIONSHIP
IADL SUPERVISION / STANDBY ASSIST
ACCOMPANY TO APPOINTMENTS
PREPARE MEALS
GROCERY SHOPPING
CHANGE BED LINEN
LAUNDRY
LIGHT HOUSEKEEPING
COSMETIC ASSISTANCE
HOURLY
DAY
DATE
TIME STARTED
DATE
TIME FINISHED
TOTAL HOURS
CHANGE IN ORIGINAL
CLIENT REVIEW AND
SCHEDULED HOURS
ACCEPTANCE (INITIAL)
SUN
MON
TUE
WED
THUR
FRI
SAT
LIVE IN HOURS WORKED
DAY
DATE STARTED
DATE FINISHED
WORKED HOURS
CLIENT REVIEW AND
ACCEPTANCE (INITIAL)
Client Care Logs may be faxed to
SUN
Administrative Services at
MON
1-800-325-6272 or emailed to
TUE
WED
THUR
FRI
SAT
By signing below I (Client) contracted with Care Provider for
By signing below I (Care Provider) certify that this
whom I certify performed all services noted above satisfactorily.
Care Log represents the actual care services requested
I understand that if services were not performed as requested, I
by Client and provided by me as the Independent Care
would not sign this care log. Care logs submitted without the
Provider for the dates listed above.
checking of Activities of Daily Living actually performed, and
required by the insurance company, may result in the
patient/client being billed directly.
Signed by Care Provider: ______________________
Signed by Client: ___________________________________

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