CALL THE OFFICE NOW IF:

• Any incident or accident • Any near miss • Changes in condition • Safety concerns • She won't eat or drink • Still in bed after 10AM • Wants bed before 8:30PM

DON'T rely on this form for urgent issues - CALL immediately!

OUR GOAL: Keep her SAFE • CLEAN • CONTENT

If she refuses something - don't argue. Wait. Try again later.

Office: (555) 123-4567

Task Codes

115
Meal
117
Meds
118
Incont
125
Walk
126
Transfer
131
Bathe
141
Super
FALL
RISK

Who & When

Morning

Get her up by 10AM. If not, CALL OFFICE.

Medications

Times: 8AM • 12PM • 5PM • 8PM

Food & Drink

If she won't eat OR drink → CALL OFFICE NOW

Cut food small • Protein each meal • No whole fruit • Snacks: cottage cheese, yogurt

Activity & Sleep

If she wants bed before 8:30PM → CALL OFFICE

Bathroom

How Is She Doing?

Daily Chores Done

✓ Label leftover food with date

✓ Wash dishes from your shift

✓ Leave home tidy

✓ Wipe toilet seat after use

✓ Empty commode at shift end

✓ Wipe kitchen counters/sink

✓ Update shopping list

✓ Hang bath mat to dry

✓ Wipe table after meals

✓ Fill pull-up drawer

✓ Hang shower rug to dry

✓ Take out trash

Weekly Tasks (if today)

Other Notes

Silver Home Care • Daily Care Report Form 251