- 2575 East 14 Street, Unit C1, Brooklyn, NY 11235
- 70-09 Austin Street, 2nd Floor, Forest Hills, NY 11375
- Office Phone: 718-650-3358 | Fax: 855-259-2365
- www.TodaysHC.com | [email protected]
HHA
PCA Duty Sheet
PATIENT
ADDRESS
EMPLOYEE
EMPLOYEE ID #
MON
TUES
WED
THUR
FRI
SAT
SUN
DATE:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
TIME STARTED:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
TIME FINISHED:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
LIVE IN:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
WALKING:
- Contact guard (041)
- Independent (040)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
TRANSFER:
- 1 Person (043)
- 2 Person (045)
- Board (046)
- Mechanical lift (047)
Monday
tuesday
wednesday
thursday
friday
Saturday
Sunday
BATH:
- Bed (018)
- Shower With Chair (014)
- Tub (015)
- Shower (016)
- Sponge (017)
- Skin Care (023)
- Foot Care (020)
Monday
tuesday
wednesday
thursday
friday
Saturday
Sunday
HAIR:
- Shampoo (021)
- Brush/Comb (029)
Monday
tuesday
wednesday
thursday
friday
Saturday
Sunday
SHAVE (022):
- Electric
- Safety Razor
Monday
tuesday
wednesday
thursday
friday
Saturday
Sunday
NAIL CARE:
- Clean/File (024)
Monday
tuesday
wednesday
thursday
friday
Saturday
Sunday
ORAL CARE (019):
- Teeth
- Dentures
Monday
tuesday
wednesday
thursday
friday
Saturday
Sunday
DRESS (027):
- Self
- Assist
- Total
Monday
tuesday
wednesday
thursday
friday
Saturday
Sunday
TURN/POSITION:
- Every 2 Hours (048)
Monday
tuesday
wednesday
thursday
friday
Saturday
Sunday
DEVICE (042):
- Crane
- Walker
- Crutches
- Wheelchair
- Weight patient (036)
Monday
tuesday
wednesday
thursday
friday
Saturday
Sunday
TOILETING:
- Commode (054)
- Bedpan/Urinal (055)
- Diaper (053)
- Toilet (025)
- Catheter Care (061)
- Empty Drainage Bag (031)
Monday
tuesday
wednesday
thursday
friday
Saturday
Sunday
INCONTINENT CARE (026):
- Bladder
- Bowel
- Remind Blood Sugar Check (050)
- Remind About Safe Sharp/Waste Disposal (98)
- Supervise Safety of Patient/Remind PERS (091)
Monday
tuesday
wednesday
thursday
friday
Saturday
Sunday
REMIND PATIENT TO TAKE MEDICATION (060):
Monday
tuesday
wednesday
thursday
friday
Saturday
Sunday
PREPARE/SERVE MEALS (058):
- Breakfast (072)
- Lunch (073)
- Dinner (074)
- Snack (075)
- Diet (071)
- Fluid Restrictions
- Encourage Fluids, Assist with Feeding (057)
Monday
tuesday
wednesday
thursday
friday
Saturday
Sunday
ACCOMPANY PT. TO:
- MD (083)
- Other (084)
- Remind to Exercise (051)
Monday
tuesday
wednesday
thursday
friday
Saturday
Sunday
RECORD:
- Fluid Intake (069)
- Output (070)
- Food Intake (076)
- Change Linen/Make Bed (079)
- Maintain Clean Safe Environment (080)
- Patient Laundry (082)
- Shopping (081)
- Diversional Activities (038)
Monday
tuesday
wednesday
thursday
friday
Saturday
Sunday
HHA ONLY
VITAL SIGNS:
- Temparature (030)
- Pulse (033)
- Respiration (034)
- Blood Pressure (035)
- Ostomy Care (064)
- Assist with Oxygen (068)
- Assist with Dressing (063)
- Active ROM/Assist with Home Exercise Program
- Other
Patient Signature
Patient Signature
MON
TUE
WED
THU
FRI
SAT
SUN
Aide Signature
Aide Signature
MON
TUE
WED
THU
FRI
SAT
SUN
Employee acknowledges and certifies to Today’s HomeCare That employee has actually worked the bumber of hours during the period set forth and as further cerfified by the patient or his authorized agent. Unsigned Duty sheets will not be accepted. Patient acknowledges and certifies that the hours set forth were actually worked and that the work was performed in a satisfactory manner. The patient should not pay the employee directly under any circumstances.
Your timesheet was submitted successfully!
An error occured.
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[field id="BathTues"]
[field id="BathWed"]
[field id="BathThurs"]
[field id="BathFri"]
[field id="BathSat"]
[field id="BathSun"]
[field id="HairMon"]
[field id="HairTues"]
[field id="HairWed"]
[field id="HairThurs"]
[field id="HairFri"]
[field id="HairSat"]
[field id="HairSun"]
[field id="ShaveMon"]
[field id="ShaveTues"]
[field id="ShaveWed"]
[field id="ShaveThurs"]
[field id="ShaveFri"]
[field id="ShaveSat"]
[field id="ShaveSun"]
[field id="NailMon"]
[field id="NailTues"]
[field id="NailWed"]
[field id="NailThurs"]
[field id="NailFri"]
[field id="NailSat"]
[field id="NailSun"]
[field id="OCMon"]
[field id="OCTues"]
[field id="OCWed"]
[field id="OCThurs"]
[field id="OCFri"]
[field id="OCSat"]
[field id="OCSun"]
[field id="DressMon"]
[field id="DressTues"]
[field id="DressWed"]
[field id="DressThurs"]
[field id="DressFri"]
[field id="DressSat"]
[field id="DressSun"]
[field id="TPMon"]
[field id="TPTues"]
[field id="TPWed"]
[field id="TPThurs"]
[field id="TPFri"]
[field id="TPSat"]
[field id="TPSun"]
[field id="DevMon"]
[field id="DevTues"]
[field id="DevWed"]
[field id="DevThurs"]
[field id="DevFri"]
[field id="DevSat"]
[field id="DevSun"]
[field id="ToiletMon"]
[field id="ToiletTues"]
[field id="ToiletWed"]
[field id="ToiletThurs"]
[field id="ToiletFri"]
[field id="ToiletSat"]
[field id="ToiletSun"]
[field id="ICMon"]
[field id="ICTues"]
[field id="ICWed"]
[field id="ICThurs"]
[field id="ICFri"]
[field id="ICSat"]
[field id="ICSun"]
[field id="MedMon"]
[field id="MedTues"]
[field id="MedWed"]
[field id="MedThurs"]
[field id="MedFri"]
[field id="MedSat"]
[field id="MedSun"]
[field id="PreMon"]
[field id="PreTues"]
[field id="PreWed"]
[field id="PreThurs"]
[field id="PreFri"]
[field id="PreSat"]
[field id="PreSun"]
[field id="AccMon"]
[field id="AccTues"]
[field id="AccWed"]
[field id="AccThurs"]
[field id="AccFri"]
[field id="AccSat"]
[field id="AccSun"]
[field id="RecMon"]
[field id="RecTues"]
[field id="RecWed"]
[field id="RecThurs"]
[field id="RecFri"]
[field id="RecSat"]
[field id="RecSun"]