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  2. 2016
  3. February
  4. L
  5. Log for Mom at Maple View
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Questions marked with a * are required Exit Survey
 
 
* Name
 
Jen
 
Michele
 
Annie
 
 
 
* DATE of visit
MonthDayYear
  
 
 
TIME: Record time spent with mom
Time
* Time In:
* Time Out:
* # of hour (in .25 increments)
 
 
 
* ON ARRIVAL: When I arrived Joyce was
 
In bed
 
In her room
 
In the hallway
 
In the dining room (eating)
 
Participating in group activity (in dining or activity room)
 
Sleepy
 
Alert

 
 
 
* JOYCE's HYGIENE and APPEARANCE: Please report any issues here
 
wet diaper
 
stained clothing
 
drooling
 
teeth not in
 
bad mood
 
Looked great!
 
Other Observations re: mom's health and/or mood (enter comments below)

 
 
 
STANDING: I got Joyce up on her feet this many times:
   
STANDING: For appox this many total minutes:
   
 
 
 
* FOOD: I supplemented Joyce's food today with (check all that apply)
 
Protein powder (1 scoop)
 
avocado
 
banana
 
Vitamin pack
 
List anything else you brought to feed mom or specifically requested from staff. Also tell us any other issues (positive or negative) re: food provided or mom's appetite.

 
 
 
* TEETH HEALTH: Today I (check those that apply)
 
did mom's teeth routine (remove teeth, brush, pick, sponge, mouthwash)
 
Noticed the following issue/problem:
 
 
 
* WOUNDS / SKIN CONDITION: Today I (check those that apply)
 
I inspected mom's ankles, legs and arms
 
I inspected mom's back
 
I inspected mom's butt
 
I inspected mom's feet & heels
 
I applied lotion
 
WRITE any changes to wound or skin condition here
 
 
 
OBSERVATIONS or INTERACTIONS w/ STAFF: I had the following conversations, or have the following suggestions for staff regarding Joyce's care:
   
 
Thanks for completing this after every visit. It will help us communicate w/ staff about mom's care & needs. (We'll also use it to track your time for pay)