Guardian Angel Monthly Reporting Sheet
Name: ______________________________
_______________________________
Signature:
Client’s Name: ______________________________
Date: _______________
Client’s residence:
_________________________________________________________________
Client has a palliative care plan: ____ No
________________________________
____ Yes with
Client has funeral arrangements: ____ No
________________________________
____ Yes with
Code Status: ________________________
Date of Visit: _______________
Length of visit: ________________
Medicine changes:
Overview of Visit/Concerns/Assistance Needed: (please observe and comment
here on your client’s overall appearance, condition of clothing, alertness, room appearance, any
physical (body) conditions of concern, were they well groomed, mood, any restraints being used, etc.
Life Essentials | 40 South Perry Street | Dayton, OH 45402
6/30/15
Date of Visit: _______________
Length of visit: ________________
Medicine changes:
Overview of Visit/Concerns/Assistance Needed: (please observe and comment
here on your client’s overall appearance, condition of clothing, alertness, room appearance, any
physical (body) conditions of concern, were they well groomed, mood, any restraints being used, etc.
Date of Visit: _______________
Length of visit: ________________
Medicine changes:
Overview of Visit/Concerns/Assistance Needed: (please observe and comment
here on your client’s overall appearance, condition of clothing, alertness, room appearance, any
physical (body) conditions of concern, were they well groomed, mood, any restraints being used, etc.
Life Essentials | 40 South Perry Street | Dayton, OH 45402
6/30/15
Date of Visit: _______________
Length of visit: ________________
Medicine changes:
Overview of Visit/Concerns/Assistance Needed: (please observe and comment
here on your client’s overall appearance, condition of clothing, alertness, room appearance, any
physical (body) conditions of concern, were they well groomed, mood, any restraints being used, etc.
Date of Visit: _______________
Length of visit: ________________
Medicine changes:
Overview of Visit/Concerns/Assistance Needed: (please observe and comment
here on your client’s overall appearance, condition of clothing, alertness, room appearance, any
physical (body) conditions of concern, were they well groomed, mood, any restraints being used, etc.
Date of Visit: _______________
Length of visit: ________________
Medicine changes:
Life Essentials | 40 South Perry Street | Dayton, OH 45402
6/30/15
Overview of Visit/Concerns/Assistance Needed: (please observe and comment
here on your client’s overall appearance, condition of clothing, alertness, room appearance, any
physical (body) conditions of concern, were they well groomed, mood, any restraints being used, etc.
Date of Visit: _______________
Length of visit: ________________
Medicine changes:
Overview of Visit/Concerns/Assistance Needed: (please observe and comment
here on your client’s overall appearance, condition of clothing, alertness, room appearance, any
physical (body) conditions of concern, were they well groomed, mood, any restraints being used, etc.
Date of Visit: _______________
Length of visit: ________________
Medicine changes:
Life Essentials | 40 South Perry Street | Dayton, OH 45402
6/30/15
Overview of Visit/Concerns/Assistance Needed: (please observe and comment
here on your client’s overall appearance, condition of clothing, alertness, room appearance, any
physical (body) conditions of concern, were they well groomed, mood, any restraints being used, etc.
Date of Visit: _______________
Length of visit: ________________
Medicine changes:
Overview of Visit/Concerns/Assistance Needed: (please observe and comment
here on your client’s overall appearance, condition of clothing, alertness, room appearance, any
physical (body) conditions of concern, were they well groomed, mood, any restraints being used, etc.
Date of Visit: _______________
Length of visit: ________________
Medicine changes:
Life Essentials | 40 South Perry Street | Dayton, OH 45402
6/30/15
Overview of Visit/Concerns/Assistance Needed: (please observe and comment
here on your client’s overall appearance, condition of clothing, alertness, room appearance, any
physical (body) conditions of concern, were they well groomed, mood, any restraints being used, etc.
Date of Visit: _______________
Length of visit: ________________
Medicine changes:
Overview of Visit/Concerns/Assistance Needed: (please observe and comment
here on your client’s overall appearance, condition of clothing, alertness, room appearance, any
physical (body) conditions of concern, were they well groomed, mood, any restraints being used, etc.
Date of Visit: _______________
Length of visit: ________________
Medicine changes:
Overview of Visit/Concerns/Assistance Needed: (please observe and comment
here on your client’s overall appearance, condition of clothing, alertness, room appearance, any
Life Essentials | 40 South Perry Street | Dayton, OH 45402
6/30/15
physical (body) conditions of concern, were they well groomed, mood, any restraints being used, etc.
Return to Jennifer Dietsch at: [email protected] or
40 South Perry Street, Dayton, OH 45402
Life Essentials | 40 South Perry Street | Dayton, OH 45402
6/30/15