Employee Flow Sheet Employee & Client Information Employee Name* First Last Email* Client First Name*Client Last Name*Office Location*Grand RapidsSaginawSt. Louis Employee ClockTime In* : HH MM AM PM Time Out* : HH MM AM PM Employee Time Worked* : HH MM AM PM Today's Date* Date Format: MM slash DD slash YYYY Actual Minutes WorkedActual Hours Worked Personal HygieneTasks Completed*HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot ApplicableTub BathShowerSponge BathPeri CareShampooHair CareSkin CareOral HygieneShave DressingTasks Completed*HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot ApplicableUpperLower MovementTasks Completed*HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot ApplicableWalkTransferRepositionExercise Prog HousekeepingTasks Completed*HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot ApplicableDustVacuumClean BathroomClean KitchenClean BedroomWash ClothesWash LinensWash Dishes Meal PrepTasks Completed*HHA/CNA completedHHA/CNA AssistedCompleted by ClientCompleted by FamilyRefusedNot ApplicableBreakfastLunchSupperSnacksAppetite*GoodFairPoor Medication*HHA/CENA's are not licensed to administer or "set up" any prescription or non-prescription medication.YesNoPrecautions Taken*YesNoEquipment used properly:Walkways clear and well lit:Universal Precautions followed:Daily Comments* SignaturesEmployee Signature*Client Signature*EmailThis field is for validation purposes and should be left unchanged.
