How to use this form

1Fill out one form per week per client. Log each shift as you complete it.

2For Services, use the abbreviation key below the table — or write out what you did.

3Print and attach to your invoice. Keep a copy in your records.

Phone

Private Care Shift Documentation

Client Name

Week Of

Invoice / Period #

#	Date	Start	End	Hrs	Services Provided	Notes / Observations
Total Hours This Week				0.0

Services Key

B = Bathing D = Dressing G = Grooming Ml = Meal prep/assist Md = Medication reminder Mb = Mobility/transfers I = Incontinence care HK = Light housekeeping C = Companionship Tr = Transportation

Weekly Notes

Caregiver Signature

Date Submitted