Caregiverlist
Daily Care Notes
Client Name: ____________________ Date: ________
Caregiver Name: _______________________________
Arrival Time:__________ Departure Time: _________
Health & Hygiene
μTransfer from bed to chair
μBathroom Visit Assistance
μCatheter Care/Diaper Change
μShower/Bed Bath
μHair care
μSkin Care/Lotion
μNail Care
μDental Care
μMedication Reminder
μExercise Routine
μNutrition
μGrocery Shopping/Meal Plan________________________
μMeal Preparation_________________________________
μSet-up Meal
μAssisted with Feeding
μFeeding Tube Care
μMeal Preparation/Foods prepared: Breakfast_______________________________________
Lunch__________________________________________
Dinner_________________________________________
Snack__________________________________________
Fluid Monitoring: Drank ______# of glasses of water or__________________________________________.
Activities
μPhysical Therapy AM/Walk
μPhyscial Therapy PM/Walk
μRead Newspaper or Book
μMental Exercise Game
μOther Activities: ___________________________________
________________________________________________________________________________________________________
Client Routine/Vitals
Wake-up Time:_________ Naptime AM:___________
Bedtime:______________ Naptime PM:____________
Bathroom Visits: ________________________________________________________________________________________________________
μWeighed in at: ________ lbs.
μBlood Pressure ________ @ ________ AM
μBlood Pressure ________ @ ________ PM
μDoctor Appointments: ________________________________
________________________________________________________________________________________________________
Indicate Client Overall Status μGood μFair μPoor
Household Cleaning
μ Changed Bed Linens μSorted Mail μDusted Rooms
μLaundry μCleaned Kitchen μCleaned Bathroom μSwept Floors
μMopped Floors μVacuumed μPet Care μChanged Bed Linens
Errands:_________________________________________________________________________________________________________________________________________________________________________________________________________
Notes to Communicate to Family: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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