AIDE ACTIVITY SHEET
Patient Name:
HHA Name:
MON
Tue
WED
THU
Fri
SAT
SUN
Date
Time In
Time Out
Client/Patient Intials
Nutrition
Prepare Meals
Serve Meals
Monitoring Fluids and liquid intake
Assist with Eating
Monitor eating behaviors
TRANSFERRING
Wheel Chair
Chair
Bed rest
Vehicle Assistance
Walker, Cane usage
DRESSING
Self
Assist
Other
PERSONAL CARE
Tub Bath/Shower
Partial/Complete Bed Bath
Sponge Bath
Usage of Bath equipment (tub seat, hand held shower)
Oral Hygiene
Skin Care Grooming
Shaving
Shampoo
Brush Teeth
Flossing
Assistance with dentures
Beard Trimming
TOILETING
Toilet
Bedside Commode
Bed Pan/Urinal
Empty Cath Drainage Bag
Empty Ostomy Appliance
Diapers/Depends
Ambulation
Ambulation
Device
Assist
Walker
MEDICATION
Medication Reminder
Initial Medication administration form
OTHER
OTHER
Date
Additional Comments
Home Health Care Aide Signature:
Print Name:
Patient/Designee: I certify that the employee on the time slip worked the times indicated and the work was performed in a satisfactory manner.
Patient/Client Signature:
Date:
[field id="Patient Name"]
[field id="HHA Name"]
[field id="date-mon"]
[field id="date-tue"]
[field id="date-wed"]
[field id="date-thu"]
[field id="date-fri"]
[field id="date-sat"]
[field id="date-sun"]
[field id="time-in-mon"]
[field id="time-in-tue"]
[field id="time-in-wed"]
[field id="time-in-thu"]
[field id="time-in-fri"]
[field id="time-in-sat"]
[field id="time-in-sun"]
[field id="time-out-mon"]
[field id="time-out-tue"]
[field id="time-out-wed"]
[field id="time-out-thu"]
[field id="time-out-fri"]
[field id="time-out-sat"]
[field id="time-out-sun"]
[field id="Client/Patient Intials Mon"]
[field id="Client/Patient Intials Tues"]
[field id="Client/Patient Intials Wed"]
[field id="Client/Patient Intials Thu"]
[field id="Client/Patient Intials Fri"]
[field id="Client/Patient Intials Sat"]
[field id="Client/Patient Intials Sun"]
[field id="Prepare Meals Mon"]
[field id="Prepare Meals Tue"]
[field id="Prepare Meals Wed"]
[field id="Prepare Meals Thu"]
[field id="Prepare Meals Fri"]
[field id="Prepare Meals Sat"]
[field id="Prepare Meals Sun"]
[field id="Serve Meals Mon"]
[field id="Serve Meals Tue"]
[field id="Serve Meals Wed"]
[field id="Serve Meals Thurs"]
[field id="Serve Meals Fri"]
[field id="Serve Meals Sat"]
[field id="Serve Meals Sun"]
[field id="Monitoring Fluids and liquid intake Mon"]
[field id="Monitoring Fluids and liquid intake Tues"]
[field id="Monitoring Fluids and liquid intake Wed"]
[field id="Monitoring Fluids and liquid intake Thu"]
[field id="Monitoring Fluids and liquid intake Fri"]
[field id="Monitoring Fluids and liquid intake Sat"]
[field id="Monitoring Fluids and liquid intake Sun"]
[field id="Assist with Eating Mon"]
[field id="Assist with Eating Tue"]
[field id="Assist with Eating Wed"]
[field id="Assist with Eating Thu"]
[field id="Assist with Eating Fri"]
[field id="Assist with Eating Sat"]
[field id="Assist with Eating Sun"]
[field id="Monitor eating behaviors Mon"]
[field id="Monitor eating behaviors Tue"]
[field id="Monitor eating behaviors Wed"]
[field id="Monitor eating behaviors Thurs"]
[field id="Monitor eating behaviors Fri"]
[field id="Monitor eating behaviors Sat"]
[field id="Monitor eating behaviors Sun"]
[field id="Wheel Chair Mon"]
[field id="Wheel Chair Tue"]
[field id="Wheel Chair Wed"]
[field id="Wheel Chair Thu"]
[field id="Wheel Chair Fri"]
[field id="Wheel Chair Sat"]
[field id="Wheel Chair Sun"]
[field id="Chair Mon"]
[field id="Chair Tue"]
[field id="Chair Wed"]
[field id="Chair Thu"]
[field id="Chair Fri"]
[field id="Chair Sat"]
[field id="Chair Sun"]
[field id="Bed rest Mon"]
[field id="Bed rest Tue"]
[field id="Bed rest Wed"]
[field id="Bed rest Thu"]
[field id="Bed rest Fri"]
[field id="Bed rest Sat"]
[field id="Bed rest Sun"]
[field id="Vehicle Assistance Mon"]
[field id="Vehicle Assistance Tue"]
[field id="Vehicle Assistance Wed"]
[field id="Vehicle Assistance Thur"]
[field id="Vehicle Assistance Fri"]
[field id="Vehicle Assistance Sat"]
[field id="Vehicle Assistance Sun"]
[field id="Walker Cane usage Mon"]
[field id="Walker, Cane usage Tue"]
[field id="Walker, Cane usage Wed"]
[field id="Walker, Cane usage Thu"]
[field id="Walker, Cane usage Fri"]
[field id="Walker, Cane usage Sat"]
[field id="Walker Cane Usage Sun"]
[field id="Self Mon"]
[field id="Self Tue"]
[field id="Self Wed"]
[field id="Self Thu"]
[field id="Self Fri"]
[field id="Self Sat"]
[field id="Self Sun"]
[field id="Assist Mon"]
[field id="Assist Tue"]
[field id="Assist Wed"]
[field id="Assist Thu"]
[field id="Assist Fri"]
[field id="Assist Sat"]
[field id="Assist Sun"]
[field id="DRESSING Other Mon"]
[field id="DRESSING Other tue"]
[field id="DRESSING Other Wed"]
[field id="DRESSING Other Thu"]
[field id="DRESSING Other Fri"]
[field id="DRESSING Other Sat"]
[field id="DRESSING Other Sun"]
[field id="Tub Bath/Shower Mon"]
[field id="Tub Bath/Shower Tue"]
[field id="Tub Bath/Shower Wed"]
[field id="Tub Bath/Shower Thu"]
[field id="Tub Bath/Shower Fri"]
[field id="Tub Bath/Shower Sat"]
[field id="Tub Bath/Shower Sun"]
[field id="Partial/Complete Bed Bath Mon"]
[field id="Partial/Complete Bed Bath Tue"]
[field id="Partial/Complete Bed Bath Wed"]
[field id="Partial/Complete Bed Bath Thu"]
[field id="Partial/Complete Bed Bath Fri"]
[field id="Partial/Complete Bed Bath Sat"]
[field id="Partial/Complete Bed Bath Sun"]
[field id="Sponge Bath Mon"]
[field id="Sponge Bath Tue"]
[field id="Sponge Bath Wed"]
[field id="Sponge Bath Thu"]
[field id="Sponge Bath Fri"]
[field id="Sponge Bath Sat"]
[field id="Sponge Bath Sun"]
[field id="Usage of Bath equipment (tub seat, hand held shower) Mon"]
[field id="Usage of Bath equipment (tub seat, hand held shower) Tue"]
[field id="Usage of Bath equipment (tub seat, hand held shower) Wed"]
[field id="Usage of Bath equipment (tub seat, hand held shower) Thu"]
[field id="Usage of Bath equipment (tub seat, hand held shower) Fri"]
[field id="Usage of Bath equipment (tub seat, hand held shower) Sat"]
[field id="Usage of Bath equipment (tub seat, hand held shower) Sun"]
[field id="Oral Hygiene Mon"]
[field id="Oral Hygiene Tue"]
[field id="Oral Hygiene Wed"]
[field id="Oral Hygiene Thu"]
[field id="Oral Hygiene Fri"]
[field id="Oral Hygiene Sat"]
[field id="Oral Hygiene Sun"]
[field id="Skin Care Grooming Mon"]
[field id="Skin Care Grooming Tue"]
[field id="Skin Care Grooming Wed"]
[field id="Skin Care Grooming Thu"]
[field id="Skin Care Grooming Fri"]
[field id="Skin Care Grooming Sat"]
[field id="Skin Care Grooming Sun"]
[field id="Shaving Mon"]
[field id="Shaving Tue"]
[field id="Shaving Wed"]
[field id="Shaving Thu"]
[field id="Shaving Fri"]
[field id="Shaving Sat"]
[field id="Shaving Sun"]
[field id="Shampoo Mon"]
[field id="Shampoo Tue"]
[field id="Shampoo Wed"]
[field id="Shampoo Thu"]
[field id="Shampoo Fri"]
[field id="Shampoo Sat"]
[field id="Shampoo Sun"]
[field id="Brush Teeth Mon"]
[field id="Brush Teeth Tues"]
[field id="Brush Teeth Wed"]
[field id="Brush Teeth Thu"]
[field id="Brush Teeth Fri"]
[field id="Brush Teeth Sat"]
[field id="Brush Teeth Sun"]
[field id="Flossing Mon"]
[field id="Flossing Tue"]
[field id="Flossing Wed"]
[field id="Flossing Thu"]
[field id="Flossing Fri"]
[field id="Flossing Sat"]
[field id="Flossing Sun"]
[field id="Assistance with dentures Mon"]
[field id="Assistance with dentures Tue"]
[field id="Assistance with dentures Wed"]
[field id="Assistance with dentures Thu"]
[field id="Assistance with dentures Fri"]
[field id="Assistance with dentures Sat"]
[field id="Assistance with dentures Sun"]
[field id="Beard Trimming Mon"]
[field id="Beard Trimming Tue"]
[field id="Beard Trimming Wed"]
[field id="Beard Trimming Thu"]
[field id="Beard Trimming Fri"]
[field id="Beard Trimming Sat"]
[field id="Beard Trimming Sun"]
[field id="Toilet Mon"]
[field id="Toilet Tue"]
[field id="Toilet Wed"]
[field id="Toilet Thu"]
[field id="Toilet Fri"]
[field id="Toilet Sat"]
[field id="Toilet Sunday"]
[field id="Bedside Commode Mon"]
[field id="Bedside Commode Tue"]
[field id="Bedside Commode Wed"]
[field id="Bedside Commode Thu"]
[field id="Bedside Commode Fri"]
[field id="Bedside Commode Sat"]
[field id="Bedside Commode Sun"]
[field id="Bed Pan/Urinal Mon"]
[field id="Bed Pan/Urinal Tue"]
[field id="Bed Pan/Urinal Wed"]
[field id="Bed Pan/Urinal Thu"]
[field id="Bed Pan/Urinal Fri"]
[field id="Bed Pan/Urinal Sat"]
[field id="Empty Cath Drainage Bag Mon"]
[field id="Empty Cath Drainage Bag Tue"]
[field id="Empty Cath Drainage Bag Wed"]
[field id="Empty Cath Drainage Bag Thu"]
[field id="Empty Cath Drainage Bag Fri"]
[field id="Empty Cath Drainage Bag Sat"]
[field id="Empty Cath Drainage Bag Sun"]
[field id="Empty Ostomy Appliance Mon"]
[field id="Empty Ostomy Appliance Tue"]
[field id="Empty Ostomy Appliance Wed"]
[field id="Empty Ostomy Appliance Thu"]
[field id="Empty Ostomy Appliance Fri"]
[field id="Empty Ostomy Appliance Sat"]
[field id="Empty Ostomy Appliance Sun"]
[field id="Diapers/Depends Mon"]
[field id="Diapers/Depends Tue"]
[field id="Diapers/Depends Wed"]
[field id="Diapers/Depends Thu"]
[field id="Diapers/Depends Fri"]
[field id="Diapers/Depends Sat"]
[field id="Diapers/Depends Sun"]
[field id="Walker Mon"]
[field id="Walker Tue"]
[field id="Walker Wed"]
[field id="Walker Thu"]
[field id="Walker Fri"]
[field id="Walker Sat"]
[field id="Walker Sun"]
[field id="Assist Mon"]
[field id="Assist Tue"]
[field id="Assist Wed"]
[field id="Assist Thu"]
[field id="Assist Fri"]
[field id="Assist Sat"]
[field id="Assist Sun"]
[field id="Device Mon"]
[field id="Device Tue"]
[field id="Device Wed"]
[field id="Device Thu"]
[field id="Device Fri"]
[field id="Device Sat"]
[field id="Device Sun"]
[field id="Ambulation Mon"]
[field id="Ambulation Tue"]
[field id="Ambulation Wed"]
[field id="Ambulation Thu"]
[field id="Ambulation Fri"]
[field id="Ambulation Sat"]
[field id="Ambulation Sun"]
[field id="Other Mon"]
[field id="Other Tue"]
[field id="Other Wed"]
[field id="Other Thu"]
[field id="Other Fri"]
[field id="Other Sat"]
[field id="Other Sun"]
[field id="Initial Medication administration form Mon"]
[field id="Initial Medication administration form Tue"]
[field id="Initial Medication administration form Wed"]
[field id="Initial Medication administration form Thu"]
[field id="Initial Medication administration form Fri"]
[field id="Initial Medication administration form Sat"]
[field id="Initial Medication administration form Sunday"]
[field id="Medication Reminder Mon"]
[field id="Medication Reminder Tue"]
[field id="Medication Reminder Wed"]
[field id="Medication Reminder Thu"]
[field id="Medication Reminder Fri"]
[field id="Medication Reminder Sat"]
[field id="Medication Reminder Sun"]
[field id="Date 1"]
[field id="Date 2"]
[field id="Date 3"]
[field id="Date 4"]
[field id="Additional Comments 1"]
[field id="Additional Comments 2"]
[field id="Additional Comments 3"]
[field id="Additional Comments 4"]
[field id="Client Sign Date"]
[field id="Print Name"]