WEEKLY VISIT REPORT
SERVICES PERFORMED: CHECK ALL THAT APPLY
Service
Light housekeeping
Light housekeeping
Meal preparation/cleanup
Meal preparation/cleanup
Medical Reminder
Medical Reminder
Shopping/Errands
Shopping/Errands
Change/menstrual/hygiene
Change/menstrual/hygiene
Bill Paying Assistance
Bill Paying Assistance
Games & Entertainment
Games & Entertainment
Spiritual encourage/prayer
Spiritual encourage/prayer
Skin/back care
Skin/back care
Complete bed bath
Complete bed bath
Partial bath
Partial bath
Tub/shower (circle type)
Tub/shower (circle type)
Peri care
Peri care
Nails (soak, file, clean)
Nails (soak, file, clean)
Brush/comb hair
Brush/comb hair
Shampoo
Shampoo
Oral hygiene/denture care
Oral hygiene/denture care
Shave
Shave
Dress/assist with dressing
Dress/assist with dressing
Date of last BM
Date of last BM
Incontinent/bathroom care
Incontinent/bathroom care
Tolerated care (G, F, P)
Tolerated care (G, F, P)
Appetite (G, F, P)
Appetite (G, F, P)
Foot care
Foot care
Encourage fluids
Encourage fluids
Feed Client
Feed Client
Turn/reposition
Turn/reposition
Walk with assistance
Walk with assistance
Feed Client
Up in chair
Transfer to chair (W/C)
Transfer to chair (W/C)
ROM (circle AROM or PROM)
ROM (circle AROM or PROM)
Empty Catheter
Empty Catheter
Exercise
Exercise
ROM Range of motion / AROM Active range of motion / PROM Passive range of motion / G/F/P Good, Fair, Poor
Additional Information
Non Routine / Emergency Care
Non Routine / Emergency Care:
Other Issues / Concerns
Reported to Supervisor (if applicable):
Other Issues / Concerns
FURTHER OBSERVATIONS: CHECK ANY POSSIBLE CONCERNS FOR SUPERVISOR FOLLOWUP
Wound care
New medications or a change in medications
Wound care
Frequent injections
Generalized weakness or debility (worsening)
Recent diagnosis changes
Shortness of breath or new on home oxygen
Unexplained weight loss
Frequent falls
New catheter, burning or frequent urination
Dementia or increased confusion
Possible physical, occupational or speech therapy needs
(Data gathering purposes only – observations to be reported to supervisor for further inquiry)
Service Date / Time
Service Date
Start Time
End Time
Monday
Start Time
:
End Time
:
Tuesday
Start Time
:
End Time
:
Wednesday
Start Time
:
End Time
:
Thursday
Start Time
:
End Time
:
Friday
Start Time
:
End Time
:
Saturday
Start Time
:
End Time
:
Sunday
Start Time
:
End Time
:
TOTAL HOURS:
:
Signature