DAY

DATE

TIME IN

TIME OUT

SUNDAY
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
TOTAL:

# OF HOURS

PATIENT/GUARDIAN SIGNATURE

EMPLOYEE SIGNATURE

WEEK OF:
/
/
THROUGH
/
/
OFFICE USE ONLY:
PAYROLL

Services

SUN

Oral Hygiene/Dentures

Personal services

Bath:Bed/Shower/Tub/tubside

Perineal Care
Shampoo
Comb/Brush Hair
Clean/File Nails
Dress: Bed/Street Cloths
Shave:Razor/Electric
Foot Care
Skin Care: Lotion/Powder/Other

Prepare for bed

Elimination

BedPan/Urinal
Commode
Catheter Care: Foley/External

Empty Catherer Bag

Record Output
Incontinence Care
Empty Colostomy bag
Diet
Meal Prep: Breakfast: Light/Full

Nutrition

Meal Prep: Lunch: Light/Full

Meal Prep: Dinner: Light/Full
Meal Prep: Snack: Light/Full

Assist with Feeding

Encourage Fluids
Record Intake
Grocery Shop
Other:

Additional Comments:

Patient's Name: Madison Conley

Medicaid # 106248777099

MON

TUES

WED

Services

SUN

MON

Bathroom
Toilet Care
Bedroom

Home Care Services

Ironing
Laundry
Change Linen/Make Bed

Kitchen
Dishes
Grocery
Refridgerator
Sweep
Wet Mop
Living Room
Dusting
Vaccum
Trash

ROM

SAT

Mobility

FRI

Turn and Position

Assist with Exercise
Other:
Transfer to Chair
Transfer to Commode
Assist with Wheelchair
Assist in Ambulation
Non-Sterile Dressing

Treatment

THUR

Temperature
Pulse
Respirations
Medication reminder
Other:

Employee's Name: Antoinette Kamba

Provider Number: 2304401

amba

TUES

WED

THUR

FRI

SAT

DATE
PERSONAL CARE SERVICES AS STATED ON THE ISP
Oral Hygiene (0-5 x week) 5-10 Min

Personal services

Bathing (0-5 x week) 5-25 Min

Dress: Bed/Street Cloths (0-5 x week) 5-10 Min
Nail Care (0-5 x week) 5-15 Min
Change Linen/Make Bed (0-5 x week) 5-10 Min
Laundry (0-5 x week) 5-10 Min
Household Chores (0-5 x week) 5-45 Min
Home Activities (0-5 x week) 5-60 Min
Community Activities (0-5 x week) 5-60 Min
Supervision (0-7 x per week) up to 24 Hours
Emergency Care (0-7 x per week) up to 24 Hours
Meal Prep: Breakfast: Light/Full

Nutrition

Meal Prep: Lunch: Light/Full

Meal Prep: Dinner: Light/Full
Meal Prep: Snack: Light/Full
Assist with Feeding
Encourage Fluids
Record Blood Pressure &/Or Weight
Grocery Shop

Staf

Time in/out: Christian Abessolo

Time in/out: Michael Abessolo

Units

Transportation

Time in/out: Kellie Johnston

Time in/out: Nicole Olama
Starting Odometer Reading
End Odometer Reading
Total Mileage
Total Number of Hours:
Total Number of Units:

SUN

MON

Units
Group Size:
Notes (please note mileage):

TUES

WED

THUR

FRI

SAT

Contract Number: 2304401

Staf Signatures:
Christian Abessolo - CA:
Michael Abessolo - MA:
Kellie Johnston - KJ:
Nicole Olama - NO:
Type of Service: HPC

Date(s) of Service:
Client Name: Alexander "Alex" Smith
DODD # : 109636712199
Place of Service:
5685 Elmgee
Delaware, OH 43015
Parent/Legal Guardian Signature

DATE
PERSONAL CARE SERVICES AS STATED ON THE ISP

Personal services

Community Activities (shopping,movies,library)

Home Activities (game playing, publishing)
Communication & Self-advocacy skills
Channeling creative passions (job development)
Skill Building (life skills, designing,ect)
Physical Activities (football,karate,paintball,walk)
Medication Reminder (Stephen Carries his box)

Units

Staf

Emergency Care (0-7 x per week) up to 24 Hours

Time in/out: Christian Abessolo
Total Number of Hours:
Total Number of Units:
Group Size:
Notes (please note mileage):

SUN

MON

TUES

WED

THUR

FRI

SAT

Contract Number: 2304401

Staf Signatures:
Christian Abessolo - CA:
Type of Service: HPC

Date(s) of Service:
Client Name: Stephen Masters
DODD # : 108456060499
Place of Service: 14728 Cleveland Rd.SW, Pataskala, OH
43062

Parent/Legal Guardian Signature

Contract Number: 2304401

Staf Signatures:
Parreco Catherine M - HM:
Type of Service: HPC

Date(s) of Service:
Client Name: MICHAEL PARRECO
DODD # : 106675314499
Place of Service: 6363 Liberty Road N., Powell, OH 43065

Parent/Legal Guardian Signature

DATE
PERSONAL CARE SERVICES AS STATED ON THE ISP
Oral Hygiene (0-5 x week) 5-10 Min

Personal services

Bathing (0-5 x week) 5-25 Min

Personal Care (0-5 x week) 5-10 Min
Household Chores (0-5 x week) 5-45 Min
Laundry (0-5 x week) 5-10 Min
Medical/Therapy (0-5 x week) 5-10 Min
Decision Making/Communication
Home Activities (0-5 x week) 5-60 Min
Community Activities (0-5 x week) 5-60 Min
Behavior Support (0-7 x per week) up to 24 Hours
Emergency Care (0-7 x per week) up to 24 Hours
Meal Prep: Breakfast: Light/Full

Nutrition

Meal Prep: Lunch: Light/Full

Meal Prep: Dinner: Light/Full
Meal Prep: Snack: Light/Full
Assist with Feeding
Encourage Fluids
Record Blood Pressure &/Or Weight

Units

TransportationStaf

Grocery Shop
Time in/out: Harold Mintsop
Time in/out:
Starting Odometer Reading
End Odometer Reading
Total Mileage
Total Number of Hours:
Total Number of Units:
Group Size:
Notes (please note mileage):

SUN

MON

TUES

WED

THUR

FRI

SAT

Contract Number: 2304401

Staf Signatures:
Parreco Catherine M - HM:
Type of Service: HPC

Date(s) of Service:
Client Name: WESLEY PARRECO
DODD # : 106328316099
Place of Service: 6363 Liberty Road N., Powell, OH 43065

Parent/Legal Guardian Signature

DATE
PERSONAL CARE SERVICES AS STATED ON THE ISP
Oral Hygiene (0-5 x week) 5-10 Min

Personal services

Bathing (0-5 x week) 5-25 Min

Personal Care (0-5 x week) 5-10 Min
Household Chores (0-5 x week) 5-45 Min
Laundry (0-5 x week) 5-10 Min
Medical/Therapy (0-5 x week) 5-10 Min
Decision Making/Communication
Home Activities (0-5 x week) 5-60 Min
Community Activities (0-5 x week) 5-60 Min
Behavior Support (0-7 x per week) up to 24 Hours
Emergency Care (0-7 x per week) up to 24 Hours
Meal Prep: Breakfast: Light/Full

Nutrition

Meal Prep: Lunch: Light/Full

Meal Prep: Dinner: Light/Full
Meal Prep: Snack: Light/Full
Assist with Feeding
Encourage Fluids
Record Blood Pressure &/Or Weight

Units

TransportationStaf

Grocery Shop
Time in/out: Alexis Yontz
Time in/out:
Starting Odometer Reading
End Odometer Reading
Total Mileage
Total Number of Hours:
Total Number of Units:
Group Size:
Notes (please note mileage):

SUN

MON

TUES

WED

THUR

FRI

SAT

DATE
PERSONAL CARE SERVICES AS STATED ON THE ISP
Oral Hygiene (0-7 x week) 5-10 Min

Personal Care services

Bathing (bathing/shower, shampoo, perinal care, comb/brush hair,

shave) (0-7 x week) 5-45 Min
Personal Care (clean/file nails, dressing, foot care, skin care, toileting)
(0-7 x week) 5-60 Min
Household Chores (cleaning bathroom, kitchen, dishes, refridgerator,
sweeping, wet mop, vacuum, changing linen/make bed) (0-7 x week)
5-60 Min
Laundry/Ironing (0-7 x week) 5-60 Min
Life Skills (teach cooking, stranger danger, portion control, empty
dishwasher) (0-7 x week) 5-10 Min
Decision Making/Communication (0-7 week) 5-10 Min
Home Activities (games, motor skills) (0-7 x week) 5-60 Min
Community Activities (swimming, shopping, etc) (0-7 x wk) 5-60 Min
Assist in Ambulation

Nutrition

Meal Prep: Breakfast: Light/Full

Meal Prep: Lunch: Light/Full
Meal Prep: Dinner: Light/Full
Meal Prep: Snack: Light/Full
Assist with Feeding
Encourage Fluids

Units

TransportationStaf

Grocery Shop
Time in/out: Antoinette Kamba
Time in/out:
Starting Odometer Reading
End Odometer Reading
Total Mileage
Total Number of Hours:
Total Number of Units:
Group Size:
Notes (please note additional information):

SUN

MON

TUES

WED

THUR

FRI

SAT

Contract Number: 2304401

Staf Signatures:
Antoinette Kamba AK:
Nicole Olama NO:

Type of Service: HPC

Office Use only: Payroll:

Date(s) of Service:
Client Name: Madison Conley
DODD # : 106248777099
Place of Service:
168 Troy Rd.
Delaware, OH 43015
Parent/Legal Guardian Signature