| Frequency |
Activities |
|
Sun
|
Mon
|
Tues
|
Wed
|
Thu
|
Fri
|
Sat
|
|
|
|
Assist - Daily Walk |
|
|
|
Assist- Exercises |
|
|
|
Assist- Stand Only |
|
|
|
Assist - Unsteady - Fall Risk |
|
|
|
Outside Activites With Assist |
|
|
|
Transfer Bed/Chair |
|
|
|
Postitioning |
|
|
|
Other: |
|
| |
|
|
| Frequency |
Diet/Meal Preparation |
|
Sun
|
Mon
|
Tues
|
Wed
|
Thu
|
Fri
|
Sat
|
|
|
|
Breakfast |
|
|
|
Lunch |
|
|
|
Dinner |
|
|
|
Other: |
|
| |
|
|
| Frequency |
Medication Reminders |
|
Sun
|
Mon
|
Tues
|
Wed
|
Thu
|
Fri
|
Sat
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| |
Medications are set-up by:
|
|
| |
|
|
| Frequency |
Personal Care |
|
Sun
|
Mon
|
Tues
|
Wed
|
Thu
|
Fri
|
Sat
|
|
|
|
Oxygen - Hygiene Care Only |
|
|
|
Assist Bathing - Bed Bath |
|
|
|
Assist Bathing - Shower |
|
|
|
Assist - Dressing |
|
|
|
Assist - Feeding |
|
|
|
Assist - Toileting |
|
|
|
Dust |
|
|
|
Change Bed Linens |
|
|
|
Clean Bathrooms |
|
|
|
Grocery Shopping |
|
|
|
Laundry |
|
|
|
Mouth Care |
|
|
|
Skin Care |
|
|
|
Take To Appointments |
|
|
|
Tidy Up |
|
|
|
Vaccuum |
|
|
|
Shampoo, Comb/Brush Hair |
|
|
|
Wash Dishes |
|
|
|
Shaving |
|
|
|
Ostomy Care-Emptying Only |
|
|
|
Support Stockings -Only If Not Prescribed by a Doctor |
|
|
|
Foley Catherter Care - Emptying Only |
|
|
|
Other: |
|
|
|
Other: |
|
| |
|
|
|
|
| |
|
|
|
|
| |
|
|
| Caregiver Recommendations: |
|
| Caregiver Notes: |
|
| |
|
|
|