- 119 Douglas Street S, Wilson, NC 27893
- Phone: (252) 265-3343
- alliancehomecarenc@gmail.com
CNA
PCA DUTY SHEET
PATIENT *
ADDRESS *
EMPLOYEE *
EMPLOYEE ID # *
SAT
SUN
MON
TUE
WED
THU
FRI
DATE:
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
TIME STARTED:
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
TIME FINISHED:
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
LIVE IN:
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
WALKING:
- Contact guard
- Independent
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
TRANSFERS:
- 1 Person
- 2 Person
- Board
- Mechanical lift
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
BATH:
- Bed
- Shower With Chair
- Tub
- Shower
- Sponge
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
- Skin Care
- Foot Care
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
HAIR:
- Shampoo
- Brush/Comb
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
SHAVE :
- Electric
- Safety Razor
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
NAIL CARE:
- Clean/File
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
ORAL CARE :
- Teeth
- Dentures
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
DRESS :
- Self
- Assist
- Total
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
TURN/POSITION:
- Every 2 Hours (048)
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
DEVICE :
- Crane
- Walker
- Crutches
- Wheelchair
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
- Weight patient (036)
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
TOILETING:
- Commode
- Bedpan/Urinal
- Diaper
- Toilet
- Catheter Care
- Empty Drainage Bag
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
INCONTINENT CARE :
- Bladder
- Bowel
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
- Remind Blood Sugar Check
- Remind About Safe Sharp/Waste Disposal
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
- Supervise Safety of Patient/Remind PERS
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
REMIND PATIENT TO TAKE MEDICATION :
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
PREPARE/SERVE MEALS :
- Breakfast
- Lunch
- Dinner
- Snack
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
- Diet
- Fluid Restrictions
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
- Encourage Fluids, Assist with Feeding
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
- Remind to Exercise
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Housekeeping
- Clear pathway/minimize cutter
- Patient Laundry
- Bathroom Cleanup
- Clean living areas
- Dispose garbage
- Dishwashing
- Sweep/Vacuum/Mop
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
- Change Linen/Make Bed
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
- Apply lotion to Dress Area
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
- Errands (Cap-Only)
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
- Maintain Clean Safe Environment
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
- Patient Laundry
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
- Shopping
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
- Diversional Activities
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
CNA ONLY
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
VITAL SIGNS:
- Temparature
- Pulse
- Respiration
- Blood Pressure
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
- Assist with Oxygen
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
- Assist with Dressing
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
- Active ROM/Assist with Home Exercise Program
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
- Other
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Patient Signature
Aide Signature
Employee acknowledges and certifies to Alliance Home Care Agency that employee has actually worked the number of hours during the period set forth and as further certified by the patient or his authorized agent. Unsigned Duty sheets will not be accepted. Patient acknowledges and certifies that the hours set forth were actually worked and that the work was performed in a satisfactory manner. The patient should not pay the employee directly under any circumstances.
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