87 Washington Street, Rensselaer, New York, 12144, T : 518-449-1142

Paraprofessional Supervisory Visit

Patient Name:             Patient DOB:  


 Aide’s Name: Time In:

AIDE PRESENT
YES NO
TREATMENT TASK OBSERVED QUALITY OF CARE
MAINTAINS INFECTION CONTROL
YES NO
BATH
SKIN CARE
PERSONAL CARE
EXCELLENT
GOOD
FAIR
POOR
KNOWLEDGEABLE OF TASKS
YES NO
ORAL CARE
INCONTINENCE CARE
AIDE COMMENTS:
DME USED
YES NO
NUTRITION
BED CARE
EXERCISE
PATIENT/SIGNIFICANT OTHER COMMENTS:
FOLLOWING POC
YES NO

IDENTIFICATION BADGE
YES NO
BLOOD PRESSURE
PULSE RESP
TEMPERATURE
WEIGHT
Medication reconciliation done: Yes No
 
DRUG NAME DOSE/FORM AMOUNT FREQ ROUTE COMMENTS
 

Aide able to communicate with patient and comprehend the plan of care.   YES     NO

Aide instructed on following POC and documenting care provided.

Progress Notes:

Patient Signature:

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Reason Patient unable to sign

If patient is unable to sign and this box is checked please enter N/A in the patient signature box

Authorized Agent Signature:

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Relationship:

Aide Signature:

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RN Signature:

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Today's Date

Time out: