Client Service Delivery Form – Personal Support

Please place a check by all tasks that were completed.

Personal Care Tasks

Bathing (tub/ shower/ bed)
Mouth /denture care
Grooming /shampooing hair /nail filing
Assisting with Dressing
Assisting with toileting /elimination
BM

MEDICALLY RELATED TASKS

Observing /reporting changes in client condition
Accompanying client on medical appointments
Reminding client to take medications
Turn client every 2 hours

HOUSEKEEPING TASKS

Vacuuming /sweeping
Dusting /mopping
Laundry /changing linens
Other

AMBULATION /TRANSFER

Assisting with transfers /walking
Encouraging with simple physical activity
Other

HOME MANAGEMENT

Grocery shopping
Assisting with bill payment
Other

PROPER NUTRITION

Preparing meals /clean up
Encouraging proper nutrition /server meal, fluids
Assisting with eating /offer snacks
Notes

Admin Signature

Ebony Holifield, RN
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