| Date (Month / Day / Year) |
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| Arrival Time: AM / PM |
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| Departure Time: AM / PM |
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| Total Hours Worked |
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| Service Provided |
| Ambulating Inside-Physically Assisted |
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| Ambulating Inside-Standby Assist |
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| Bathing - Physically Assisted |
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| Bathing - Standby Assist |
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| Bathing - Verbal Cue or Reminder |
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| Dressing - Physically Assisted |
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| Dressing - Standby Assist |
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| Dressing - Verbal Cue or Reminder |
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| Eating - Spoon Fed or Tube Fed |
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| Eating - Verbal Cue or Reminder |
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| Transfer out of bed/chair - Physically Assist |
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| Transfer out of bed/chair - Standby Assist |
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| Transfer out of bed/chair - Verbal Cue or Reminder |
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| Toileting - Physically Assist |
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| Toileting - Standby Assist |
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| Toileting - Verbal Cue or Reminder |
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| Incontinent of bowel/bladder - Physically Assisted |
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| Assistance with Colostomy/Catheter Care |
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| Provided Continual Supervision due to Cognitive |
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| Impairment: Cannot be left alone |
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| Provided Continual Supervision due to a Physical Functional |
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| Incapacity: Cannot be left alone |
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| Companion Services |
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| Homemaking/Housekeeping - laundry, meal prep, dust, wash, dishes, other: |
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