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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Print Name:
Relationship:

Aide Signature:

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RN Signature:

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Print Name

Today's Date

Time out:



                       

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