Homecare Services in Loganville, GA

Client Information

Who was visited and where

Select Client

Client Name

Address

Visit Date

Client or Responsible Party

Client or Responsible Party Phone Number

Reason for Visit

Staff assigned and what was observed during the visit

Assigned Staff

Present During Visit?

Satisfactory Performance?

Tasks Observed

Training Provided?

Compare the visiting supervisor's assessment with the client's own comments

Item Visitor Client

Temperature

Blood Pressure

Pulse

Respiration

If vital signs could not be obtained, note the reason in Client's General Conditions below.

Client's General Conditions

Review of Progress Made

Problems Encountered

Client's Service Satisfaction

Appropriateness of Service

Cost of Service Provided

Safety and Hygiene

Client's / Responsible Party's Initial

Date

Review Supervisor's Name

Supervisor's Signature

Date