Daily Time Sheet

*

The Sun Home Health Care Delaware The Sun Home Health The Sun Home Health Care Columbus

Employee Name *

Patient's Name *

Have you ever came in contact with COVID 19 positive person?

Yes No Don't Know

Are you currently experiencing symptoms (cough, shortness of breath, fever)?

Yes No Don't Know

Please Contact to Home office Immediatley

Phone No: 740 362 5035

Have your patient ever came in contact with COVID 19 positive person?

Yes No Don't Know

Have your patient currently experiencing symptoms (cough, shortness of breath, fever)?

Yes No Don't Know

Please Contact to Home office Immediatley

Phone No: 740 362 5035

Sun Program *

Sun Code *

Delaware Program *

Delaware Code *

CMH Program *

CMH Code *

Date *

Hour Minutes AM/PM Option

Start Time *

: Hour Minutes

End Time *

: Hour Minutes

Start Evv Done *

Yes No

End Evv Done *

Yes No

Start Reason *

End Reason *

Total Hours

Type a question

Job Done

Turn & Position

Mobility Assist

ROM exercises

Ambulation Assist

Vacuuming

Dust/Damp Mop

Kitchen cleaned

Dishes

Bathroom

Make/Change Bed

Empty commode

Empty trash

Laundry/Client's home

Laundry/Laundromat

Wash stove top

Clean refrigerator

Dust

Mirrors/Windows

Errands

Shopping

Prescription pickup

Appt accompany

Grocery shopping

Cash-received

Cash-returned

Client Refused/client not home

Other

Pesonal Care

Job Done

Bath/Shower

Tube/Bed

Hair Care

Shampoo

Shave

Mouth/Denture Care

Oral Care-swab/brush

Assist with Dressing

Lotion/Skin barrier

Help with toileting

Nail Care

Wash/rub back

Check for skin breakdown

Catheter Care

Abdomen/None

Hands/Feet

Legs(R/L)

Diet Order

Food Allergies

Limit/Enc Fluids

Meals Preparation

Feeding/Serving

BP/BS check reminders

Medication Reminders

Other

I hereby certify that the hours recorded on this document are correct and that the work reflected by this time was performed in a satisfactory manner. This document is submitted as documentation of and for billing services rendered. In addition, I certify that the client and associate named by signature above did not receive any injuries/unusual incidents during the assignment.

By signing this time sheet you are agreeing that the task performed the listed duties on the dates and times shown.

Total Hours Done = *

Employee Signature *

Clear

Patient's Signature *

Clear

Activities