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HOME HEALTH AIDE CARE PLAN

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					Mid Ohio Home Health Care, LLC
6430 E Main St. Suite 102
Reynoldsburg, OH 43068
Phone (614) 751-9780 Fax (614) 751-9782
                                                                       HOME HEALTH AIDE VISIT NOTE

                     CLIENT NAME:                                                                          CLIENT ID:
                     HHA PRINTED NAME:                                                  TOTAL (T) “√”       ASSIST (A) “√”            PAY #


DATE                     DATE                      DATE                         DATE                        DATE                        DATE                        DATE
SUNDAY               T A MONDAY                T A TUESDAY                T   A WEDNSDAY              T   A THURSDAY              T   A FRIDAY                T   A SATRDAY               T   A
BATHING                  BATHING                   BATHING                      BATHING                     BATHING                     BATHING                     BATHING
Tub / Shower             Tub / Shower              Tub / Shower                 Tub / Shower                Tub / Shower                Tub / Shower                Tub / Shower
Bed: Partial             Bed: Partial              Bed: Partial                 Bed: Partial                Bed: Partial                Bed: Partial                Bed: Partial
     Complete                 Complete                  Complete                     Complete                    Complete                    Complete                    Complete
Perineal Care            Perineal Care             Perineal Care                Perineal Care               Perineal Care               Perineal Care               Perineal Care
Shampoo Hair             Shampoo Hair              Shampoo Hair                 Shampoo Hair                Shampoo Hair                Shampoo Hair                Shampoo Hair
Comb Hair                Comb Hair                 Comb Hair                    Comb Hair                   Comb Hair                   Comb Hair                   Comb Hair
Mouth Care               Mouth Care                Mouth Care                   Mouth Care                  Mouth Care                  Mouth Care                  Mouth Care
Shave                    Shave                     Shave                        Shave                       Shave                       Shave                       Shave

DRESSING                  DRESSING                   DRESSING                    DRESSING                    DRESSING                    DRESSING                    DRESSING
Find Clothing             Find Clothing              Find Clothing               Find Clothing               Find Clothing               Find Clothing               Find Clothing
Dress Upper Body          Dress Upper Body           Dress Upper Body            Dress Upper Body            Dress Upper Body            Dress Upper Body            Dress Upper Body
Dress Lower Body          Dress Lower Body           Dress Lower Body            Dress Lower Body            Dress Lower Body            Dress Lower Body            Dress Lower Body

SKIN CARE                 SKIN CARE                  SKIN CARE                   SKIN CARE                   SKIN CARE                   SKIN CARE                   SKIN CARE
Apply Lotion              Apply Lotion               Apply Lotion                Apply Lotion                Apply Lotion                Apply Lotion                Apply Lotion
Massage                   Massage                    Massage                     Massage                     Massage                     Massage                     Massage

NAIL CARE                 NAIL CARE                  NAIL CARE                   NAIL CARE                   NAIL CARE                   NAIL CARE                   NAIL CARE
Clean / File Nails        Clean / File Nails         Clean / File Nails          Clean / File Nails          Clean / File Nails          Clean / File Nails          Clean / File Nails
Foot Care                 Foot Care                  Foot Care                   Foot Care                   Foot Care                   Foot Care                   Foot Care

TIDINESS                  TIDINESS                   TIDINESS                    TIDINESS                    TIDINESS                    TIDINESS                    TIDINESS
Clean Bedroom             Clean Bedroom              Clean Bedroom               Clean Bedroom               Clean Bedroom               Clean Bedroom               Clean Bedroom
Clean Bathroom            Clean Bathroom             Clean Bathroom              Clean Bathroom              Clean Bathroom              Clean Bathroom              Clean Bathroom
Clean Kitchen             Clean Kitchen              Clean Kitchen               Clean Kitchen               Clean Kitchen               Clean Kitchen               Clean Kitchen
Make Bed                  Make Bed                   Make Bed                    Make Bed                    Make Bed                    Make Bed                    Make Bed
Light Dusting             Light Dusting              Light Dusting               Light Dusting               Light Dusting               Light Dusting               Light Dusting

ELIMINATION               ELIMINATION                ELIMINATION                 ELIMINATION                 ELIMINATION                 ELIMINATION                 ELIMINATION
Toileting                 Toileting                  Toileting                   Toileting                   Toileting                   Toileting                   Toileting
Empty BSC                 Empty BSC                  Empty BSC                   Empty BSC                   Empty BSC                   Empty BSC                   Empty BSC
Clean BSC                 Clean BSC                  Clean BSC                   Clean BSC                   Clean BSC                   Clean BSC                   Clean BSC
Empty Catheter            Empty Catheter             Empty Catheter              Empty Catheter              Empty Catheter              Empty Catheter              Empty Catheter
Catheter Care             Catheter Care              Catheter Care               Catheter Care               Catheter Care               Catheter Care               Catheter Care
Change                    Change                     Change                      Change                      Change                      Change                      Change
Disposables               Disposables                Disposables                 Disposables                 Disposables                 Disposables                 Disposables

ACTIVITY                  ACTIVITY                   ACTIVITY                    ACTIVITY                    ACTIVITY                    ACTIVITY                    ACTIVITY
Repositioning             Repositioning              Repositioning               Repositioning               Repositioning               Repositioning               Repositioning
Ambulation                Ambulation                 Ambulation                  Ambulation                  Ambulation                  Ambulation                  Ambulation
Wheelchair                Wheelchair                 Wheelchair                  Wheelchair                  Wheelchair                  Wheelchair                  Wheelchair
Walker                    Walker                     Walker                      Walker                      Walker                      Walker                      Walker
Chair Transfer            Chair Transfer             Chair Transfer              Chair Transfer              Chair Transfer              Chair Transfer              Chair Transfer
Bed Transfer              Bed Transfer               Bed Transfer                Bed Transfer                Bed Transfer                Bed Transfer                Bed Transfer
Range of Motion           Range of Motion            Range of Motion             Range of Motion             Range of Motion             Range of Motion             Range of Motion

NUTRITION                 NUTRITION                  NUTRITION                   NUTRITION                   NUTRITION                   NUTRITION                   NUTRITION
Meal Prep                 Meal Prep                  Meal Prep                   Meal Prep                   Meal Prep                   Meal Prep                   Meal Prep
Set-up                    Set-up                     Set-up                      Set-up                      Set-up                      Set-up                      Set-up
Feed                      Feed                       Feed                        Feed                        Feed                        Feed                        Feed
Encourage Fluids          Encourage Fluids           Encourage Fluids            Encourage Fluids            Encourage Fluids            Encourage Fluids            Encourage Fluids

ADDITIONAL                ADDITIONAL                 ADDITIONAL                  ADDITIONAL                  ADDITIONAL                  ADDITIONAL                  ADDITIONAL
TASKS                     TASKS                      TASKS                       TASKS                       TASKS                       TASKS                       TASKS
Laundry                   Laundry                    Laundry                     Laundry                     Laundry                     Laundry                     Laundry
Change Linens             Change Linens              Change Linens               Change Linens               Change Linens               Change Linens               Change Linens
Vacuum / Mop              Vacuum / Mop               Vacuum / Mop                Vacuum / Mop                Vacuum / Mop                Vacuum / Mop                Vacuum / Mop
Wash Dishes               Wash Dishes                Wash Dishes                 Wash Dishes                 Wash Dishes                 Wash Dishes                 Wash Dishes
Errands                   Errands                    Errands                     Errands                     Errands                     Errands                     Errands
Remove Trash              Remove Trash               Remove Trash                Remove Trash                Remove Trash                Remove Trash                Remove Trash




 DATE                                           CLIENT SIGNATURE                                      HHA SIGNATURE                     TIME IN               TIME OUT
                      SUNDAY
                      MONDAY
                      TUESDAY
                      WEDNESDAY
                      THURSDAY
                      FRIDAY
                      SATURDAY

				
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posted:8/9/2011
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