Passport Supervisory Report Form
Client Name
*
Primary Diagnosis
*
Date
*
/
Month
/
Day
Year
HM/HHA Services
*
Excellent
Good
Average
Poor
Comments
Adherence to Care Plan
Recording/Reporting
Problems/Changes
Dress Code
promptness
Attendance
Personal Care
Quality of Service
Functional Status
*
Unchanged
Improved
Changed
Comments
Medical
Mental Status
Mobility
Nutrition
Skin
List Type of Service (HHA/HM/RSP)and Service Schedule
*
HHA Present
*
HM/HHA(Name)
*
Title
*
Nursing Care Plan Reviwed with Client/Caregiver and HHA/HM
*
Service Care Plan Reviewed with Client/Caregiver and HHA/HM
*
COMMENTS : (Problems, Plans, Unmet Needs, Safety Hazards, Changes in Informal Caregiver Status, Client Teaching, Contacts with Case Manager)
Client/Caregiver Signature
*
Clear
Supervisor Signature
Clear
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