Visit Report Staff Name *Enter your First and Last NameClient's Name *Enter Client's First and Last NameVisit Date *Enter Visit DateArrival Time *Time you arrived to client's homeHours-120102030405060708091011Minutes-000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859AMPMDeparture Time *Time you left client's homeHours-120102030405060708091011Minutes-000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859AMPMVisit Duration Hours *Enter # of Hours of the VisitVisit Duration Minutes *Enter # of Minutes of VisitClient RefusalDid Client Refuse VisitYesNoClient Refusal ReasonVisit RushedDo you or the client feel like the visit was rushed and there was not enough time?YesNoVisit rushed reasonVisit Time ExtendedIndicate (IN MINUTES) how long the visit has been extended beyond the scheduled end time.Extension ReasonVisit Time ShortenedIndicate (IN MINUTES) how long the visit has been shortened from the scheduled end time.Shorten ReasonPhysical ConditionGeneral ObservationsNote your general observations about the client that requires attention. Examples are: redness in their skin, wound on their body, not their typical strength or condition, etc.Vitals - BPEnter blood pressure value, side of body BP was taken, time of day it was taken, client position when taken, and client activity prior to BP measurement.Vitals - PulseEnter pulse rate value.Vitals - RespirationsEnter respirations count (count respirations within 30 seconds and multiply count by 2)MobilityNote changes to client's mobility.Symptoms or ComplaintsIndicate if client is experiencing any symptoms or voicing complaints (only indicate what is UNUSUAL/OUT OF THE CLIENT's NORM).Emotional WellbeingMood and SocializationIndicate changes in client's mood and socialization. Example, client is more sad than usual, client does not want to go out or is being more isolated, etc.HomeMaintenance and SafetyIndicate safety risks and areas in the home that require repair for you to safely do your job and for the client to be safe.Home SuppliesIndicate home supplies including groceries that are running low and require replenishment. Example, hand soaps, towels, milk, eggs, etc.Medical SuppliesIndicate medical supplies that are running low and require replenishment. Example, gloves, gowns, catheter bags, etc.Care PlanFill out fields that are included in the care planCare Completed as per Care PlanWere all instructions on the care plan followed?YesNoCare plan instructions not followedCare Plan requires updatingDoes any part of the care plan require updating?YesNoUpdates requiredPersonal CareNote your observations while providing personal care. Example if client requiring more assistance than usual, client more resistive, etc.Medication AssistanceIndicate medication issues such as error, low supply, etc.Meals and NutritionIndicate meals prepared for client, what was consumed and how much, fluid intake and output of client, etc.ExerciseNote client's participation with their exercise program including duration and effort.HomemakingNote any concerns.Special ProgramsIndicate client's progress with special programs. Example, with the dementia program, indicate client's participation, if you are noticing worsening of memory or ability to do activities, etc.IncidentsFalls or InjuriesIndicate if the client had a fall or suffered any injury from an accident.Medical IncidentsIndicate any medication error regardless of cause.Near MissIndicate any close calls or near accidents/injuries.SummaryClient FeedbackIndicate client feedback about the visit and care you provided.ConcernsIndicate any other concerns you have observed during the visit.Consent *By submitting this form, you attest and agree to the following: You have personally completed the visit as indicated. The information provided are true and accurate. Any falsehood will invalidate the visit and may impact your subsequent compensation and potential employment with TotalCare Concierge. Submit ReportSave as DraftPlease do not fill in this field.
