Gentle Care Home Services, Inc. 1180 Stelton Road, Piscataway, NJ 08854 Tel. (732) 777-0021 Fax (732) 777-0224 E-mail: [email protected] Patient Name: (Last)______________________________________ (First)_____________________________________ Case #____________ Address: ________________________________________________ City: _______________________________ State: NJ Zip: ___________ RN Please FAX TO (732) 777-0224 CODES: R=Refused √= Completed S=See Notes Program: JACC Week of: CAP MCMAP Respite VA GO Private T20 T3B Medicaid MON Date: HOURS WORKED: (FROM-TO) AM or PM APS CCPED TUE WED 1. Please write the date you - provided - care here. TOTAL HOURS WORKED PERSONAL CARE: NEVER use whiteout 1. Tub bath on any timesheets 2. Shower being submitted. It will 3. Sponge bath be returned to you so it 4. Mouth care can be redone before 5. Foot care being paid. 6. Shampoo 7. Nail care/Skin care ELIMINATION: 8. Toileting: diaper, bedpan, urinal, commode, toilet 9. Incontinent care 10. Dressing 11. Infant care VITAL SIGNS: 12. Temperature: oral, rectal, axillary (By RN Q visit) 13. Pulse (By RN Q visit) 14. Respirations (By RN Q visit) 15. Weight ACTIVITIES/EXERCISES: 16. Walking 17. Walking/Guarding 18. Walking with device: cane, walker, crutches 19. Transfer: 1 person, 2 people, slide board, mech. lift 20. Turning and positioning 21. Exercises: Active ROM, Passive ROM NUTRITION: 22. Feed, assist with feeding 23. Meal prep: breakfast, lunch, dinner, snacks DIET: Regular 2gm NA 1800 ADA Low fat MEDICATIONS: 24. Assist/Remind 25. Catheter care, change external catheter ENVIRONMENT CARE: 26. Clean: pt. room, bathroom, kitchen, pt. care equipment 27. Grocery Shopping 28. Laundry 29. Accompany to MD/Clinic SAFETY: 30. Do not leave unattended, bed rail up BY SIGNING, THE PATIENT/FAMILY AGREES TO VERIFY HOME HEALTH AIDE VISIT. PATIENT/FAMILY MEMBER SIGNATURE 7. 6. Here you must print your name. DYFS Other _____________________ THUR FRI SAT SUN 02/03 12:00 PM 2:00 PM 2 hrs 2. Please - write-the time you provided care here. - Frequency 3. Please write the Q total Visit hours you provided care here. Q Visit Q Visit Q Visit Q Visit Q Visit Q Visit Care Plan Codes: . Q QV/Q Visit Visit – Every Visit QWK/Q Week – Every Week Q PRN Visit – As Needed 4. This main area is where you will document all care given. A simple check mark is all it takes!! Please note if care is refused or not needed by marking an “R”. Make sure you follow the Plan of Care the Nurse has created! Q Visit Q Week PRN At All Times Here you must sign your name. 5. After every shift, make sure you have your patient signs in these boxes. (USE BLUE PEN) 8. Here you must write your ID number. (Found on your GCHS Employee ID card) Care Plan Date __________________ RN Signature ___________________________ Patient/Family CG Signature __________________________________ HHA: Print Name: _____________________________________ Signature: ____________________________________ ID#: __________