Employee Flow Sheet

* indicates are required entry

Employee & Client Information

Your name * :

Your email * :

Your Employee ID#* :

Today's Date* (MM-DD-YYYY) :

Client Name *

Time In* :

Time Out* :

Total Hours* :


Personal Hygiene - Task Completed

Tub Bath
HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot Completed

Shower
HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot Completed

Sponge Bath
HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot Completed

Peri Care
HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot Completed

Shampoo
HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot Completed

Hair Care
HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot Completed

Skin Care
HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot Completed

Oral Hygiene
HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot Completed

Shave
HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot Completed


Dressing - Task Completed

Upper
HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot Completed

Lower
HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot Completed


Movement - Task Completed

Walk
HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot Completed

Transfer
HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot Completed

Reposition
HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot Completed

Exercise Prog
HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot Completed


Meal Prep - Task Completed

Breakfast
HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot Completed

Lunch
HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot Completed

Supper
HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot Completed

Snacks
HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot Completed

Appetite
GoodFairPoor


Housekeeping - Task Completed

Dust
HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot Completed

Vacuum
HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot Completed

Clean Bathroom
HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot Completed

Clean Kitchen
HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot Completed

Clean Bedroom
HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot Completed

Wash Clothes
HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot Completed

Wash Linens
HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot Completed

Wash Dishes
HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot Completed


Miscellaneous - Task Completed

Shopping
HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot Completed

Errands
HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot Completed

Dr. Appointment
HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot Completed

Other
HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot Completed


Medication - Task Completed

HHA/CENA's are not licensed to administer or "set up" any prescription or non-prescription medication.

Medication
YesNo


Precautions Taken

Equipment used properly:
YesNo

Walkways clear and well lit:
YesNo

Universal Precautions followed:
YesNo



Daily Comments:

Your Signature:

Client Signature: