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HOME HEALTH CARE DAILY PROGRESS NOTES

Policyholder: Both sides of this form are to be completed by your caregiver in the event they do not have their own letterhead or billing forms. Please sign the statement at the bottom of the page to certify the care provided by the caregiver. Client Name Policy Number Home Health Aide: Yes _____ No _____ Company Name Caregiver Name Trained at CNA: Yes Week Beginning Caregiver SSI # No State Number 20

Day/Date Time In Time Out

Personal Care: Tub Bath/ Shower Assistance Bed Bath/ Sink Bath Shampoo Hair Shave Client Mouth Care Dressing Assistance Eating: Feed Client Toileting: Urinal/ Bedpan Transfer to toilet or commode Diaper Foley Catheter/ Ostomy Care Activity: Walks without help Uses cane/ walker/ crutches/ wheelchair Needs hands on help w/ walking

Mon AM PM AM PM

Tue AM PM AM PM

Wed AM PM AM PM

Thurs AM PM AM PM

Fri AM PM AM PM

Sat AM PM AM PM

Sun AM PM AM PM

Please check any Assistance with Activities of Daily Living you give to the Client

Assistance to chair/ wheelchair/ bed Please check any Assistance with Instrumental Activities of Daily Living you give to the Client only Prepare or serve meal Grocery Shopping Cleaning Laundry Transportation (where?) Errands (where?) Hours out of home I certify that the care listed is an accurate account of the care given and received

Policyholder Signature Caregiver Signature

Date Date

Page 1 of 3

HOME HEALTH CARE DAILY PROGRESS NOTES (PAGE TWO) CLIENT NAME Notes must be written each day. Things to includes are: WEEK BEGINNING

· Special Skin care · Ability to take medications · Wound Care or Treatment · How you found client when you arrived · Change in Client's condition · Explain care provided in more detail

Monday / / Total Hours ( ) Tuesday / / Total Hours ( ) Wednesday / / Total Hours ( ) Thursday / / Total Hours ( ) Friday / / Total Hours ( ) Saturday / / Total Hours ( ) Sunday / / Total Hours ( )

Caregiver Signature

Caregiver Signature

Caregiver Signature

Caregiver Signature

Caregiver Signature

Caregiver Signature

Caregiver Signature

Page 2 of 3

HOME HEALTH CARE PROVIDER FORM THIS FORM SHOULD BE COMPLETED AND SIGNED BY THE INSURED'S PROVIDER OF HOME HEALTH CARE SERVICES. Name of insured: Date of Service Hours Worked Charge per Hour Policy No. Total Charge

Signature by Provider License or Certificate # (if applicable)

Name of Provider (please print) Relationship to Insured

Page 3 of 3

Information

3 pages

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