DAILY SERVICE NOTE
Provider’s Name: Personal Touch Professional Services Il Individual's Name: Jack Weckerly DOB: 10/16/1975 MCI: 002790492 W Code (s): W9029/ W9030 Service Location Address: 1609 Church Lane, Apt B,, Philadelphia, Pa, 19141 Service Delivered: Licensed Residential Hab W/Day or Licensed Residential Hab W/O Day Unit of Service: 1 Day
Date
*
-
Month
-
Day
Year
Date Picker Icon
Date Of Service
*
-
Month
-
Day
Year
Date
Please indicate the hours worked:
*
8am-12am
12pm-4pm
8am- 4pm
4 pm-12 am
12am-8am
Other
Other: If hours worked are different from hours listed above. Please document here:
Did Jack attend any appointments?
*
Yes
No
If yes, please provide the name of the provider, type of appointment, and any changes or recommendations. If not applicable, put N/A.
*
Hygiene: Bathing/Showering
Rows
Independent
Assisted
Refused
Overnight Sleep
Completed 1st Shift
Hygiene: Bathing/Showering
Hygiene: Oral Care
Note any hygiene Issues or Concerns: If not applicable, put N/A.
Meal Consumption: Food/ Drink consumed
Rows
100%
25%
50%
0%
Breakfast
Lunch
Dinner
If consumed 0% of food or drinks state why in the box below.
Back
Next
Outcome Phrase: INDEPENDENCE
Goal: Jack will assist with cooking twice weekly (Please select how Jack assisted with cooking meals):If you select the option "other" please explain?
*
Chopped up food
Monitor food while cooking
Help prepare menu
Food Preparation
Supermarket Shopping
Jack prepared his meal independently while the staff monitored
N/A Overnight Shift
Other
Was Goal Completed/Not Completed?
*
Goal Completed
Not Completed
If the goal was not completed on the shift, please select why:If you select the option "other" please explain?
*
Jack was Sleeping
Jack Refused
Jack decided to Eat out
Staff Papered Meal Independently
N/A Overnight Shift
Other
Provide Summary of Shift: Note if the goal was completed along with support given and progress. If not completed, explain why.
*
Staff Printed Name :
*
Staff Title:
*
Date:
*
Signature
*
Submit
Should be Empty: