* Required Information
WEEKLY VISIT RECORD
Employee Name
*
Week beginning Sunday
Week beginning Saturday
Client Name
Total Weekly Hours
VISIT 1
DATE
IN
OUT
CLIENT NAME
EMPLOYEE NAME
DAILY HOURS
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
VISIT 2
DATE
IN
OUT
CLIENT NAME
EMPLOYEE NAME
DAILY HOURS
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Please initial in the appropriate boxes to indicate tasks completed
GROOMING AND DRESSING
VISIT 1
VISIT 2
ASSIGNMENT
SU
MO
TU
WE
TH
FR
SA
SU
MO
TU
WE
TH
FR
SA
Hair Care
VISIT 1
VISIT 2
Shampoo
VISIT 1
VISIT 2
Skin Care
VISIT 1
VISIT 2
Mouth/Dent
VISIT 1
VISIT 2
Foot Care
VISIT 1
VISIT 2
Nail Care
VISIT 1
VISIT 2
Dressing
VISIT 1
VISIT 2
Other
VISIT 1
VISIT 2
BATHING
VISIT 1
VISIT 2
ASSIGNMENT
SU
MO
TU
WE
TH
FR
SA
SU
MO
TU
WE
TH
FR
SA
Personal Care
VISIT 1
VISIT 2
Tub Bath
VISIT 1
VISIT 2
Shower
VISIT 1
VISIT 2
Bed Bath Part
VISIT 1
VISIT 2
Bed Bath Comp
VISIT 1
VISIT 2
Sponge Bath
VISIT 1
VISIT 2
Other
VISIT 1
VISIT 2
AMBULATION/ASSISTIVE DEVICE USE
VISIT 1
VISIT 2
ASSIGNMENT
SU
MO
TU
WE
TH
FR
SA
SU
MO
TU
WE
TH
FR
SA
Walker
VISIT 1
VISIT 2
Cane
VISIT 1
VISIT 2
Wheel Chair
VISIT 1
VISIT 2
BSC
VISIT 1
VISIT 2
ROM EXER(PT/OT)
VISIT 1
VISIT 2
Home Exercise
VISIT 1
VISIT 2
Reposition in Bed
VISIT 1
VISIT 2
Other
VISIT 1
VISIT 2
HOUSEKEEPING
VISIT 1
VISIT 2
ASSIGNMENT
SU
MO
TU
WE
TH
FR
SA
SU
MO
TU
WE
TH
FR
SA
Light Laundry
VISIT 1
VISIT 2
Change Bed LN
VISIT 1
VISIT 2
Make Bed
VISIT 1
VISIT 2
Light Cleaning
VISIT 1
VISIT 2
Bedroom
VISIT 1
VISIT 2
Bathroom
VISIT 1
VISIT 2
Kitchen
VISIT 1
VISIT 2
Clean Equip
VISIT 1
VISIT 2
Dust
VISIT 1
VISIT 2
Sweep
VISIT 1
VISIT 2
Vacuum
VISIT 1
VISIT 2
Trash
VISIT 1
VISIT 2
Feed/Care Pets
VISIT 1
VISIT 2
Water Plants
VISIT 1
VISIT 2
Other
VISIT 1
VISIT 2
NUTRITION/HYDRATION
VISIT 1
VISIT 2
ASSIGNMENT
SU
MO
TU
WE
TH
FR
SA
SU
MO
TU
WE
TH
FR
SA
Prep Meal(Diet)
VISIT 1
VISIT 2
Fluid Intake
VISIT 1
VISIT 2
Assist Feeding
VISIT 1
VISIT 2
Remind Oral Sup
VISIT 1
VISIT 2
Other
VISIT 1
VISIT 2
PERFORM/ASSIST WITH PROCEDURES
VISIT 1
VISIT 2
ASSIGNMENT
SU
MO
TU
WE
TH
FR
SA
SU
MO
TU
WE
TH
FR
SA
Wound Drg
VISIT 1
VISIT 2
Pressure Points
VISIT 1
VISIT 2
Hygeine/Toiltg
VISIT 1
VISIT 2
Ostomy Care
VISIT 1
VISIT 2
Catheter Care
VISIT 1
VISIT 2
Catheter Bag
VISIT 1
VISIT 2
Med Reminder
VISIT 1
VISIT 2
Other
VISIT 1
VISIT 2
Comments
ANDORRA (+376)
UNITED ARAB EMIRATES (+971)
AFGHANISTAN (+93)
ANTIGUA AND BARBUDA (+1268)
ANGUILLA (+1264)
ALBANIA (+355)
ARMENIA (+374)
NETHERLANDS ANTILLES (+599)
ANGOLA (+244)
ARGENTINA (+54)
AMERICAN SAMOA (+1684)
AUSTRIA (+43)
AUSTRALIA (+61)
ARUBA (+297)
AZERBAIJAN (+994)
BOSNIA AND HERZEGOVINA (+387)
BARBADOS (+1246)
BANGLADESH (+880)
BELGIUM (+32)
BURKINA FASO (+226)
BULGARIA (+359)
BAHRAIN (+973)
BURUNDI (+257)
BENIN (+229)
SAINT BARTHELEMY (+590)
BERMUDA (+1441)
BRUNEI DARUSSALAM (+673)
BOLIVIA (+591)
BRAZIL (+55)
BAHAMAS (+1242)
BHUTAN (+975)
BOTSWANA (+267)
BELARUS (+375)
BELIZE (+501)
CANADA (+1)
COCOS (KEELING) ISLANDS (+61)
CONGO,THE DEMOCRATIC REPUBLIC OF THE (+243)
CENTRAL AFRICAN REPUBLIC (+236)
CONGO (+242)
SWITZERLAND (+41)
COTE D IVOIRE (+225)
COOK ISLANDS (+682)
CHILE (+56)
CAMEROON (+237)
CHINA (+86)
COLOMBIA (+57)
COSTA RICA (+506)
CUBA (+53)
CAPE VERDE (+238)
CHRISTMAS ISLAND (+61)
CYPRUS (+357)
CZECH REPUBLIC (+420)
GERMANY (+49)
DJIBOUTI (+253)
DENMARK (+45)
DOMINICA (+1767)
DOMINICAN REPUBLIC (+1809)
ALGERIA (+213)
ECUADOR (+593)
ESTONIA (+372)
EGYPT (+20)
ERITREA (+291)
SPAIN (+34)
ETHIOPIA (+251)
FINLAND (+358)
FIJI (+679)
FALKLAND ISLANDS (MALVINAS) (+500)
MICRONESIA,FEDERATED STATES OF (+691)
FAROE ISLANDS (+298)
FRANCE (+33)
GABON (+241)
UNITED KINGDOM (+44)
GRENADA (+1473)
GEORGIA (+995)
GHANA (+233)
GIBRALTAR (+350)
GREENLAND (+299)
GAMBIA (+220)
GUINEA (+224)
EQUATORIAL GUINEA (+240)
GREECE (+30)
GUERNSEY (+44)
GUATEMALA (+502)
GUAM (+1671)
GUINEA-BISSAU (+245)
GUYANA (+592)
HONG KONG (+852)
HONDURAS (+504)
CROATIA (+385)
HAITI (+509)
HUNGARY (+36)
INDONESIA (+62)
IRELAND (+353)
ISRAEL (+972)
ISLE OF MAN (+44)
INDIA (+91)
IRAQ (+964)
IRAN,ISLAMIC REPUBLIC OF (+98)
ICELAND (+354)
ITALY (+39)
JAMAICA (+1876)
JORDAN (+962)
JAPAN (+81)
JERSEY (+44)
KENYA (+254)
KYRGYZSTAN (+996)
CAMBODIA (+855)
KIRIBATI (+686)
COMOROS (+269)
SAINT KITTS AND NEVIS (+1869)
KOREA DEMOCRATIC PEOPLES REPUBLIC OF (+850)
KOREA REPUBLIC OF (+82)
KUWAIT (+965)
CAYMAN ISLANDS (+1345)
KAZAKSTAN (+7)
LAO PEOPLES DEMOCRATIC REPUBLIC (+856)
LEBANON (+961)
SAINT LUCIA (+1758)
LIECHTENSTEIN (+423)
SRI LANKA (+94)
LIBERIA (+231)
LESOTHO (+266)
LITHUANIA (+370)
LUXEMBOURG (+352)
LATVIA (+371)
LIBYAN ARAB JAMAHIRIYA (+218)
MOROCCO (+212)
MONACO (+377)
MOLDOVA,REPUBLIC OF (+373)
MONTENEGRO (+382)
SAINT MARTIN (+1599)
MADAGASCAR (+261)
MARSHALL ISLANDS (+692)
MACEDONIA,THE FORMER YUGOSLAV REPUBLIC OF (+389)
MALI (+223)
MYANMAR (+95)
MONGOLIA (+976)
MACAU (+853)
NORTHERN MARIANA ISLANDS (+1670)
MAURITANIA (+222)
MONTSERRAT (+1664)
MALTA (+356)
MAURITIUS (+230)
MALDIVES (+960)
MALAWI (+265)
MEXICO (+52)
MALAYSIA (+60)
MOZAMBIQUE (+258)
NAMIBIA (+264)
NEW CALEDONIA (+687)
NIGER (+227)
NIGERIA (+234)
NICARAGUA (+505)
NETHERLANDS (+31)
NORWAY (+47)
NEPAL (+977)
NAURU (+674)
NIUE (+683)
NEW ZEALAND (+64)
OMAN (+968)
PANAMA (+507)
PERU (+51)
FRENCH POLYNESIA (+689)
PAPUA NEW GUINEA (+675)
PHILIPPINES (+63)
PAKISTAN (+92)
POLAND (+48)
SAINT PIERRE AND MIQUELON (+508)
PITCAIRN (+870)
PUERTO RICO (+1)
PORTUGAL (+351)
PALAU (+680)
PARAGUAY (+595)
QATAR (+974)
ROMANIA (+40)
SERBIA (+381)
RUSSIAN FEDERATION (+7)
RWANDA (+250)
SAUDI ARABIA (+966)
SOLOMON ISLANDS (+677)
SEYCHELLES (+248)
SUDAN (+249)
SWEDEN (+46)
SINGAPORE (+65)
SAINT HELENA (+290)
SLOVENIA (+386)
SLOVAKIA (+421)
SIERRA LEONE (+232)
SAN MARINO (+378)
SENEGAL (+221)
SOMALIA (+252)
SURINAME (+597)
SAO TOME AND PRINCIPE (+239)
EL SALVADOR (+503)
SYRIAN ARAB REPUBLIC (+963)
SWAZILAND (+268)
TURKS AND CAICOS ISLANDS (+1649)
CHAD (+235)
TOGO (+228)
THAILAND (+66)
TAJIKISTAN (+992)
TOKELAU (+690)
TIMOR-LESTE (+670)
TURKMENISTAN (+993)
TUNISIA (+216)
TONGA (+676)
TURKEY (+90)
TRINIDAD AND TOBAGO (+1868)
TUVALU (+688)
TAIWAN,PROVINCE OF CHINA (+886)
TANZANIA,UNITED REPUBLIC OF (+255)
UKRAINE (+380)
UGANDA (+256)
UNITED STATES (+1)
URUGUAY (+598)
UZBEKISTAN (+998)
HOLY SEE (VATICAN CITY STATE) (+39)
SAINT VINCENT AND THE GRENADINES (+1784)
VENEZUELA (+58)
VIRGIN ISLANDS,BRITISH (+1284)
VIRGIN ISLANDS,U.S. (+1340)
VIET NAM (+84)
VANUATU (+678)
WALLIS AND FUTUNA (+681)
SAMOA (+685)
KOSOVO (+381)
YEMEN (+967)
MAYOTTE (+262)
SOUTH AFRICA (+27)
ZAMBIA (+260)
ZIMBABWE (+263)
Select a country first.