* = Required Information
Shift Report Form - 3223 14th Ave. S
This form is to be completed for each shifted worked.
Name
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This form is confidential. It will be sent only to your Lead DSP.
Date
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Select shift worked
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8:30am - 5:00 pm
3:00 pm - 11:00 pm
5:00 pm - 11:00 pm
11:00 pm - 8:30 am
8:30 am - 11:00 pm
Which Primary Check-in meeting was completed today:
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Please note the resident's name requests made, items needed (hygiene or personal), goals discussed. etc.
Which resident completed laundry today:
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Please include if clothes and/ or linens were washed. Linens must be washed weekly.
Appointments that took place during shift:
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Please place the referral form in the back of the resident's program book.
Did each resident complete their hygiene routine?
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Yes
No
If anyone refused to complete hygiene, please note the resident name and what was declined:
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Please place the referral form in the back of the resident's program book.
Meals prepared during shift:
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Please include if a resident prepared the meal with staff.
Community Meeting participation:
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Include which residents participated and the topic(s) discussed.
Messages to pass along from this shift:
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Please include messages from team members, clinics, other AHSCS site, etc.
Maintenance issues observed or reported:
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Please include smoke detectors beeping, burnt out, light bulbs, vehicle issues, slow draines, etc.
Activities that took place during the shift:
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Include which residents participated and the topic(s) discussed.
Maintenance issues observed or reported:
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Please include smoke detectors beeping, burnt out, light bulbs, vehicle issues, slow draines, etc.
Activities that took place during the shift:
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Please note any activities missed, and the reason they were missed.
Community Meeting:
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Include which residents participated and the topic(s).
Medical Concerns observed or reported:
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Include action taken during your shift (e.g. administered PRN, contacted nurse, etc).
Well-Being Checks
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Any additional information, questions, concerns, or observations:
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Please include any recommendations you have for improvement.
Reminder: This form is confidential and is only submitted to your Lead DSP.
Submit