Daily Care Log

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Daily Care Log

Please complete this form at the end of each shift and submit.

Email *

Client Name *

Caregiver *

(First & Last)

Date of Care *

YYYY

Monitor Safety/Fall Prevention *

Yes

Required

Mobility *

Walker

Cane

Wheelchair

Standby Assist all ADL

Required

Transferring *

Yes

Not Needed

Medication Reminder *

Yes

Required

Meals *

Select all that apply, including meals served

Encourage Fluids

Prep Serve

Breakfast

Lunch

Dinner

Special Diet

Required

Toileting *

Select all that apply

Continent

Incontinent

Change briefs

Standby assist

Required

Hygiene *

Select all that apply

Bathing

Hair Care

Oral-Care

Shaving

Not Needed

Required

Dressing or Undressing Assist *

Yes

Not Needed

Companionship *

Mental Stimulation

Errands Appointments

Required

Exercise *

Select all that apply

Walking

Range of Motion

Physical Therapy

Not Needed

Required

Home Care *

Select all that apply

Light Housekeeping

Laundry

Change Linens

Take out trash

Not Needed

Required

Comments or Notes about shift care

By answering yes, this constitutes an electronic signature confirming the information on this form is correct and the care provided. *

Yes

Required

A copy of your responses will be emailed to the address you provided.

Submit

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