Home Care Schedule and Activities Record

This checklist will assist you with documenting instructions for a caregiver coming to take care of your loved one and for the caregiver to document what happened during his/her shift that day. Each day, fill out the top part of the form with any appointments your loved one has that day and any duties you would like completed in the home. Leave the form with the caregiver to fill out during his or her shift noting what your loved one ate, medications he or she took, and any other relevant information about what happened while the caregiver was looking after your loved one.

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