Aide Note
CarePlus Home Health, Inc.
Tel: 301.740.8870 Fax: 301.740.8871
19390 Montgomery Village Avenue
Montgomery Village, MD 20886-3000
DUE EVERY MONDAY BY 12NOON
Caregiver: Please complete this form every week to document your hours worked as well as the care given to the client.
Client Name: ________________________________________
CG Name:______________________________________
Mon
Tue
Wed
Thu Fri
Date:
Pay Period Ending Sunday:______/______/______
Signature_____________________________________
Sat
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Time In:
am
pm
am
pm
am
pm
am
pm
am
pm
am
pm
am
pm
am
pm
am
pm
am
pm
am
pm
am
pm
am
pm
am
pm
Time Out:
am
pm
am
pm
am
pm
am
pm
am
pm
am
pm
am
pm
am
pm
am
pm
am
pm
am
pm
am
pm
am
pm
am
pm
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Daily Hours Worked
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WEEKLY HOURS WORKED
Follow Plan of Care and 
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Indicate Assistance Given to Client.
PERSONAL CARE
COMPLETE BATH
PARTIAL BATH
TUB
SHOWER
ORAL HYGIENE
BRUSH / COMB HAIR
SHAMPOO
SHAVE
LOTION
PERINEAL CARE
CATHETER CARE
DRESSING ASSISTANCE
MOBILITY
BEDREST
TURN / POSITION q2
AMBULATION
ASSIST
WALKER
CANE
WHEELCHAIR
SCOOTER
TRANSFER-BED/CHAIR
R.O.M EXERCISES
SUPERVISE MEDICATION
TEMPERATURE
PULSE
RESPIRATION
WEIGHT
ELIMINATION
TOILET / COMMODE
BEDPAN / URINAL
# OF DIAPER CHANGES
CATHETER
OSTOMY
NUTRTION
PREPARE MEAL / SNACK
INDEPENDENT IN EATING
ASSIST IN FEEDING
HOUSE CLEANING
DISPOSE EXPIRED FOOD
TIDY KITCHEN
TIDY BATHROOM
TIDY BEDROOM
CHANGE LINEN
LAUNDRY/DUST/ VACUUM
HOUSE KEY LOCATION__________
SHOPPING/ RUN ERRANDS
DOG WALKED/ LET OUT
TRANSPORTATION (CIRCLE ONE)
DOCTOR, HAIR, OTHER
COMPANION TIME (talk, read, walk)
Revised 3/2015
© 2015 CarePlus
Aide Note Submission Schedule
Start
Revised 3/2015
End
1/12/2015
to
1/25/2015
1/26/2015
to
2/8/2015
2/9/2015
to
2/22/2015
2/23/2015
to
3/8/2015
3/9/2015
to
3/22/2015
3/23/2015
to
4/5/2015
4/6/2015
to
4/19/2015
4/20/2015
to
5/3/2015
5/4/2015
to
5/17/2015
5/18/2015
to
5/31/2015
6/1/2015
to
6/14/2015
6/15/2015
to
6/28/2015
6/29/2015
to
7/12/2015
7/13/2015
to
7/26/2015
7/27/2015
to
8/9/2015
8/10/2015
to
8/23/2015
8/24/2015
to
9/6/2015
9/7/2015
to
9/20/2015
9/21/2015
to
10/4/2015
10/5/2015
to
10/18/2015
10/19/2015
to
11/1/2015
11/2/2015
to
11/15/2015
11/16/2015
to
11/29/2015
11/30/2015
to
12/13/2015
12/14/2015
to
12/27/2015
12/28/2015
to
1/10/2016
1/11/2016
to
1/24/2016
1/25/2016
to
2/7/2016
2/8/2016
to
2/21/2016
2/22/2016
to
3/6/2016
3/7/2016
to
3/20/2016
3/21/2016
to
4/3/2016
4/4/2016
to
4/17/2016
4/18/2016
to
5/1/2016
5/2/2016
to
5/15/2016
5/16/2016
to
5/29/2016
5/30/2016
to
6/12/2016
6/13/2016
to
6/26/2016
© 2015 CarePlus