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Home Health Aide Progress Note

Patient Name:

MR#

Case Manager/Nurse

Frequency/Duration: AIDE Visits:

Patient Diagnosis

Patient Problems/Needs

Goals for care:

Goals for care:

effective and safe personal care patient clean, comportable other (specify)

Goals for care:

initial recertification change in patient condition other:

Other, please specify

Other, please specify

Safety and other pertinent information - Check all that apply

Safety and other pertinent information - Check all that apply

Lives Alone Lives with others Alone during the day Bed Bound Up as tolerated

Safety and other pertinent information - Check all that apply

Amputee (specify)

Amputee (specify)

Safety and other pertinent information - Check all that apply

Vision problem: Glasses Contacts

Safety and other pertinent information - Check all that apply

Hard of Hearing Hearing Aid

Safety and other pertinent information - Check all that apply

Dentures Upper Lower Partial

Safety and other pertinent information - Check all that apply

Oriented Alert Forgetful Confused Ostomy Urinary Cather

Safety and other pertinent information - Check all that apply

Artificial limb (specify)

Artificial Limb (specify)

Safety and other pertinent information - Check all that apply

Food Allergies

Food Allergies (specify)

Safety and other pertinent information - Check all that apply

Other

Other, please specify

Safety and other pertinent information - Check all that apply

Pest/rodent infested

Safety and other pertinent information - Check all that apply

Inadequate Heat Cooling Plumbing Pest/rodent infested Presence of animals

Safety and other pertinent information - Check all that apply

Supplies

Supplies (specify)

Activities ordered by RN

Home Health Aide Services Provided: = ✔ Frquency: QV = Every Visit A = Assist

Frequency

date

Time In

Time Out

Patient Initials Each Visit

Patient Initials Each Visit

Bath Bed Chair Tub Shower

Hair care - Comb/Brush

Hair care - Comb/Brush

Shampoo

Shampoo

Oral Hygiene:

Clean Dentures Brush Swab

Skin Care:

Lotion Deodorant Foot Care

Goals b

QV A

Goals b

QV A

Goals b

QV A

Goals b

QV A

Goals b

QV A

Back Rub:

Shave Other

Back Rub

Goals b

QV A

Nail Hygine

Clean File

Goals b

QV A

Assist with Dressing

Assist with Dressing

Goals b

QV A

Patient Initials Each Visit

Chair Bedside Dangle Toilet Shower/Tub

Goals b

QV A

Ambulation Assist:

W/C Walker Cane

Goals b

QV A

Patient Initials Each Visit

Catheter Care Empty Catheter Bag

Goals b

QV A

Record I/O

Record I/O

Record

Goals b

QV

Date of Last Bowel Movement

Date of Last Bowel Movement

Goals b

QV

Meal Preparation

Meal Preparation: Diet Assist w/ feeding

Meal Preparation Diet

Goals b

QV A

Fluids

Fluids: Limit Encourage

Goals b

QV

Linens

Linens: Change Wash Make Bed

Goals b

QV A

Light Housekeeping

Light Housekeeping: Bedroom Bath Kitchen

Goals b

QV A

Fluids

Standard Precautions Safety Check

Goals b

QV A

Other tasks

Other tasks:

Other Tasks

Goals b

QV A

Temp:

po AX Rect

Report >

Goals b

QV Temp

Pulse:

Pulse: Report

Pulse

Goals b

QV Pulse

Resp: Report

Resp: Report

Resp: Report

Goals b

QV Resp

B/P: Report

B/P: Report

B/P

Goals b

QV BP

Weight: Report

Weight: Report gain loss

lbs/wk

Goals b

QV WT

Home Health AIDE Initials

Each Visit

SUn

Date

Time In

Time Out

Mon

Date

Time In

Time Out

Tue

Date

Time In

Time Out

wed

Date

Time In

Time Out

Thu

Date

Time In

Time Out

Fri

Date

Time In

Time Out

Sat

Date

Time In

Time Out

Report to RN:

Red or broken skin, No BM in days Vital Signs/Weight outside of parameters Safety Issues

Report to RN

Comments:

Supervisor Signature:

Supervisor Signature

Date:

Date

Home Health Aide Signature:

Home Health Aide Signature

Patient Siganture:

Patient Siganture

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[email protected]
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