Sunset over a lake, serving as a decorative background.

SHIFT INVOICE and
NOTES

(To be completed at the end of the shift)

ANY MISSING DISBURSEMENTS MUST BE SENT BY INVOICE AND WILL NOT BE PAID FROM THIS FORM

Contractor Name*

Client First Name*

Client Last Name*

DATE OF SERVICE*

Start Time:

Start Time
AM/PM

End Time:

End Time
AM/PM

Total Shift Hours* How many total hours?
ex 8.25

MILEAGE ONLY DRIVING FOR OR WITH PATIENTPut how many miles driven with or for patient.

What was the Mileage for if you have mileage above?

CARE NOTES BELOW MUST BE COMPLETED FOR
THIS DAY BEFORE SUBMITTING FORM

Personal and
Hands on CareSelect All
that Apply:

Shower/Bath

Assist with Dressing

Assist with Bathroom Needs

Assist with Transfers

Assist with ambulation

None of the Above

Turn/Reposition

Oral/Hair Care

Skin Care

Peri Care

Vitals

None of the Above

SAFETY*

Fall Precautions Maintained

Aspiration / swallowing precautions maintained

Supervision with meals

Assisted Feeding

Medication Reminders

None of the Above

Home Making*

Light Housekeeping

Laundry

Groceries

Prepare Meals / Snack

None of the Above

Percentage of
Meals Eaten

Percentage of
Fluids Consumed

Number of
Bowel Movements

Urine

Foley Cath Output

Signature*

Sign Here

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