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
 
FOLLOWING POC
YES NO

IDENTIFICATION BADGE
YES NO
BLOOD PRESSURE
PULSE RESP
TEMPERATURE
WEIGHT
PATIENT/SIGNIFICANT OTHER COMMENTS:

Progress Notes:
Medication reconciliation done:  Yes No

Patient Signature:

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Reason Patient unable to sign

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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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