HHA

PCA DUTY SHEET

PATIENT *

ADDRESS *

EMPLOYEE *

EMPLOYEE ID # *

MON

TUES

WED

THUR

FRI

SAT

SUN

DATE:

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TIME STARTED:

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TIME FINISHED:

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LIVE IN:

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WALKING:

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TRANSFERS:

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BATH:

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HAIR:

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SHAVE (022):

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NAIL CARE:

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ORAL CARE (019):

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DRESS (027):

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TURN/POSITION:

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DEVICE (042):

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TOILETING:

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INCONTINENT CARE (026):

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REMIND PATIENT TO TAKE MEDICATION (060):

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PREPARE/SERVE MEALS (058):

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ACCOMPANY PT. TO:

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RECORD:

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HHA ONLY

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