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Step
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Caregiver Name
*
First
Last
Date in / Time-in
*
Date
Time
Date out / Time- out
*
Date
Time
Client's Name
*
First
Last
Next
Total Hours worked
*
Daily Tasks
BA (Bathing/Sponging)
BR (Dressing)
MD (Medication Supervison)
EA (Eating/Meal/Feeding)
AM (Ambulation Assistance)
CS (Cognitve Supervision)
LS (Laundry)
Notes
*
Comment
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