Employee Flow Sheet Employee & Client Information Employee Name* First Last Email* Client First Name* Client Last Name* Office Location* Grand Rapids Saginaw St. Louis Employee ClockTime In* : Hours Minutes AM PM AM/PM Time Out* : Hours Minutes AM PM AM/PM Employee Time Worked* : Hours Minutes AM PM AM/PM Today's Date* MM slash DD slash YYYY HiddenActual Minutes WorkedHiddenActual 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* Good Fair Poor Medication*HHA/CENA's are not licensed to administer or "set up" any prescription or non-prescription medication. Yes No Precautions 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.
