Activity Sheet must reach our office by 12 noon on Wednesday for processing
Extended Hands Home Care Agency
155 Atlantic City Blvd, Bayville, NJ 08721
(551) 733-6078
info@theextendedhands.com
SUN
MON
TUES
WED
THU
FRI
SAT
Date
Time Started
Time Ended
Total Hours
Errand Miles
Client Signature / Initial
Total Weekly Hours
DAILY ACTIVITIES
SUN
MON
TUES
WED
THU
FRI
SAT
Positioning:
- Up as Tolerated
- T&P every 2 hours
Bathing:
- Shower
- Sponge
- Bed Bath
- Chair
Hair Care:
- Shampoo
- Shower
- Bed
- Groom
Skin Care:
- Lotion
- Nail/Foot - do not cut
- Shave (electric)
Dressing:
- Assist
- Complete
- Day
- Evening
Ambulation:
- Walking (guard while ambulatory)
- Cane
- Walker
- Wheelchair
ROM:
- Active
- Passive
- Elevate Lower Extremities
Transfer:
- Bed to Chair
- Hoyer Lift
- Pivot
Diet:
- Fluids
- Encourage
- Restrict
- Regular
- DASH
- Low Fat
- Diabetic
Medications:
- Remind Medications
- Apply Cream
- Medi-Planner
Elimination:
- Toilet
- Commode
- Bed Pan
- Measure I/O
- Catheter
Light Housekeeping:
- Bedroom
- Bathroom
- Kitchen