VITAL SIGNS NOTES - Nursing Management

NURSING MANAGEMENT, INC.
CLIENT CARE ASSIGNMENT / DAILY NOTE
Client’s Name:
BLACK INK ONLY.
Caregiver’s Name:
(Not NMI F/S)
Date Rec’d (NMI Only): ____________
Rec’d By (NMI Only):_______________
Provider / Field Staff Name:
Title:
Provider's Signature/Title Date Time In a / p Time Out a / p Total Hours Client/Legal Representative’s Signature
Client/Legal Representative: Your signature on this form validates that all documentation on this note is correct.
Type of Client
VAR AAHK Other:
Vital Signs: (If Applicable)
B/P: Heart Rate: Respirations: Temperature:
IF YOU ASSISTED OR COMPLETED TASKS LISTED, PLEASE PLACE CHECKMARK IN BOX TO RIGHT.
General Care
Nutrition Care (Assist / Complete)
Companionship / Supervision
Meal Preparation
Relieve Caregiver Burn-out
Meal Clean Up
Patient Teaching
Feeding
Orient to Person, Place & Time
Encourage Fluids
Assist with Medication Reminders
Other:
Play / Socialization Activities
Treatment Care
Assess & Monitor Care
Catheter Care (CNAs Only)
Mental Status
Monitor NG Tube Care / G-Tube Care
Health Status
Monitor Oxygen Therapy
Nutrition Status
Monitor Dressing Change
Elimination Status
Monitor Decubitus Care
Safety Precautions
Monitor Intake
Seizure Precautions
Monitor Output
Aspiration Precautions
Other:
Other:
Housekeeping Needs
Personal Care (Assisted or Completed)
Make / Change Bed
Bed Bath / Tub Bath / Shower
Clean Bedroom (Dust / Vacuum)
Partial Bath
Clean Living Room (Dust / Vacuum)
Shampoo / Comb Hair
Clean Kitchen (Stove / Refrigerator / Mop)
Mouth Care (Brush Teeth / Dentures)
Clean Bathroom (Tub / Toilet / Mop)
Shave
Laundry (Wash / Dry)
Dressing (Change Client’s Clothes)
Trash Taken Out
Skin Care
Equipment Cleaned
Foot / Back Care
Other:
Clean / File Nails (Do not cut)
Homemaker & HCS Only
Other: Picked up Prescriptions ($ Received)
Perineal Care General Shopping ($ Received)
Assist Urinal / Bed Pan Paying Client’s Bills ($ Received)
Assist to Bedside Commode / Toilet Money Returned: $
Mobility Care (Assist with)
ID/DD HCS Only
Ambulation / Walking
Picked up at (State Place):
Wheelchair / Walker / Cane
Dropped off at (State Place)
Transfer Chair / Bed
Escort to Appointments (State Place)
Range of Motion Exercises
Escort to Events (State Place)
Reposition Client every 2 hours
Escort to Dining Out (State Place)
Other:
Other:
Client Received From:
Client Given To:
(OVER)

NURSING MANAGEMENT, INC.
All Notes Are Due Every Wednesday by 5pm. Black Ink Only.
Date of Shift:
Client’s Name:
Provider/Field Staff’s Name:
1. Did you receive any new information from the family regarding the client? Yes No
If Yes, explain:
2. Has the family notified you that they will be out of town and will not need services? Yes No
If Yes, explain and contact NMI:
3. Were there any changes, concerns or incidents during this shift? Yes No
If Yes, explain and contact NMI:
4. Did you leave client clean, dry with no complaints? Yes No
If No, explain:
Include am/pm
Time
DOCUMENT; TIME IN, CHANGES IN CLIENT, TIME OUT
Narrative Notes
Initials
Program Director’s Signature
Date