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  1. Surveys
  2. 2016
  3. January
  4. L
  5. Log for Mom at Glastonbury Health Center
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Questions marked with a * are required Exit Survey
 
 
* 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:
   
 
 
 
OBSERVATIONS re: staff care: I observed staff doing the following (include task & time - ie: feeding her at 5:30, toileting her at 12:00, etc).
   
 
 
 
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)