Activity Daily Log Template - Cerna Homecare
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1Activity Daily Log
Client Name:
Caregiver Name:
Instructions: Please write in the date for each day of the week. Write in your specific shift time on the days you worked, write NA
on days you did not work for this client. Use Key below for each task completed with your client. Write specific notes below task
list to explain a change in condition or important note or concern. Sign and date from.
S=
Stand-by assistance as needed or caregiver supervision
A=
Assistance from caregiver required to complete task
D=
Dependent, performed by caregiver
I=
Independent, performed without any assistance from caregiver
X=
Not done on while on shift
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Date
Shift Time
NA=Did not work
Bathing
Grooming
Meal
Preparation
Medication
Reminder
Dressing
Exercise
Transferring
Toileting
Appointments,
transportation
Light
Housekeeping
Other:
Notes:
Cargiver Signature:
Date:
ADLs are due by 5pm every Monday the following Monday by 5pm of every week.
Fax 949-253-4169
Email
Cerna Healthcare, Business Center Drive, Irvine, CA 92612
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