Client Care Notes

Client Care Notes Form

PLEASE ONLY COMPLETE AND DOCUMENT TASKS THAT ARE ON THE CLIENT’S CARE PLAN. If a client requests services not on the care plan, please call the office to discuss.

Client Initials: (Use initials only for security purposes)


Caregiver Name:


Date of Service


Shift Start Time


Shift End Time

Please check all performed and refused tasks.

COMPANIONSHIP TASKS
Companionship Performed
Refused
Protective Oversight Performed
Refused
HOUSEKEEPING TASKS
Housekeeping, General Performed
Refused
Personal Laundry Performed
Refused
Trash Performed
Refused
MEALS TASKS
Encourage Fluids Performed
Refused
Feeding (State Limited) Performed
Refused
Meal Preparation Performed
Refused
MEDICATION REMINDERS
Medication Reminder Performed
Refused
MOBILITY TASKS
Contact Assist Performed
Refused
Exercise Reminder Performed
Refused
Standby Assist Performed
Refused
Transfer Assist Performed
Refused
OUTINGS
Errands/Shopping Performed
Refused
Transportation Performed
Refused
PERSONAL CARE TASKS
Bathing Performed
Refused
Catheter Care (State Limited) Performed
Refused
Dressing Assist Performed
Refused
Incontinence Care Performed
Refused
Oral Care (State Limited) Performed
Refused
Oxygen Performed
Refused
Personal Hygiene Performed
Refused
Repositioning (Directed) Performed
Refused
Shampoo Performed
Refused
Shaving (Electric Only) Performed
Refused
Skin Care, Special Performed
Refused
Toileting Performed
Refused