Daily Care Report - Form 251

with Instructions Combined -->

Plan of Care & Instructions

Effective 05-11-2020 - Click each row to see detailed instructions

Code Task Level Schedule Details
115 Meal Preparation Full Breakfast, Lunch, Dinner + Snacks
116 Housework/Chores Full Daily + Weekly tasks
117 Medication Reminders Verbal/Prompt Morning, Afternoon, Evening, Bedtime
118 Incontinence Care Hands On After each toileting + as needed
120 Transportation Full As needed (office approval required)
122 Hygiene Full/Prompt Daily - Morning & as needed
123 Dressing Upper Full Daily - Morning & evening
124 Dressing Lower Full Daily - Morning & evening
125 Locomotion Full All ambulation - hands-on assistance
126 Transfer Full All transfers - Bed, toilet, shower, wheelchair
127 Toilet Use Hands On Every 2 hours + as needed
128 Bed Mobility Full Repositioning every 2 hours + as needed
129 Eating Prompting All meals - Supervision & prompting
130 Bladder Incontinence Hands On Every 2 hours + as needed
131 Bathing Full/Prompt Daily shower as accepted
132 Personal Care Full Daily - Morning & evening
134 Wash Up Full After meals & toileting + as needed
135 Shower Full Daily as scheduled/accepted
140 Bowel Incontinence Hands On After each episode + as needed
141 Supervision Full Continuous - Never leave alone
142 Activity & Rest Full Daily - Naps as needed

Today's Shift

Hygiene

Medication Reminder

Note: She will take them independently with meals.

Food & Hydration

Activity & Rest

Note: Client should be up by 10:00 AM. Please encourage her to stay up until 9:00 PM if possible.

Bathroom Activity

Please assist with pericare and maintain proper hygiene after each episode.

How Is She Doing Today?

Please observe how the client is feeling and behaving throughout your shift.

Daily & As-Needed Tasks

Complete these tasks during every shift as needed:

Weekly Scheduled Tasks

Complete these tasks on their assigned days. Check each task when completed:

Mon Monday

Tue Tuesday

Wed Wednesday

Thu Thursday

Fri Friday

Sat Saturday

Sun Sunday

No scheduled tasks

Any Other Notes?

Please share anything else about the day's care that we should know about.

Safety Reminders

  • • Client is a fall risk - use caution with all mobility
  • • Hands-on assistance required for all ambulation and transfers
  • • At night: Keep baby monitor within view - be aware if she is trying to get up. Don't just rely on the bed alarm
  • • Maintain physical contact when client is standing or walking

Call The Office Right Away If:

• Any incident, accident, or near miss

• Any changes in her condition

• Any concerns about her safety

• She refuses to eat or drink

• She doesn't get up by 10:00 AM

• She wants to go to bed before 8:30 PM

Note: This form may not be read right away. For anything urgent, always call the office immediately rather than relying on the form.

Our Goal: Keep her safe, clean, and content. If she doesn't want to do something, don't argue — just wait and try again later.

Office Phone: (555) 123-4567

Caregiver Signature & Attestation

By signing below, I attest that the information provided in this daily report is true and accurate to the best of my knowledge. I acknowledge that I have reviewed and understand the client's Plan of Care as stated above.