BI-NACL Return complete form to: BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25332-3151 In-home Nursing / Attendant Care Log Claimant Name Service Vendor Claim Number Ordering Physician Date Submitted Authorization Number Date Range of Service (from/ to) Saturday Sunday Vendor Number Monday Tuesday Wednesday Thursday Friday Time Approved—Daily Time Arrived Time Left Total Hours Claimant’s Initials Ci r c l e t h e a p p r o p r i a t e t a s k a n d p l a c e a c h e c k ma r k f o r d a y t h e t a s k wa s p e r f o r m e d . Ac t iv i t i es o f D ai l y L i vi n g ( A D L ) Tasks: Saturday Sunday Monday Tuesday Wednesday Thursday Friday Ambulation: walk / cane / walker / wheelchair / scooter Bath: total / assist / supervised / independent sponge / tub / shower Dressing: total / assist / supervise / independent Hair: total / assist / supervise / independent Meals: diet breakfast / lunch / dinner plan / prep / set-up / feed / record intake Mouth care: total / assist / supervise / independent Positioning: turn every hrs. / up in chair Skin care: lotion / shaving / catheter / bedsores H o m e Ca r e Toileting: bathroom / bedpan / bedside commode Incontinent / empty catheter bag or ostomy device / record output total / assist / supervise / independent Bathroom: sweep / mop / clean fixtures / toilet / bedpan / bedside commode or urinal / straighten / empty trash Bed making: hospital bed / regular bed Client’s room: Twice weekly: straighten Weekly: vacuum / sweep / mop / dust Entire Residence: vacuum / sweep / mop / Dust / straighten Kitchen: vacuum / sweep / mop / countertops / dishes / straighten Laundry: Laundromat / in home / apt. complex He al t h Ca re Exercise: ROM / prescribed Phys. Therapy total / assist / supervise / independent Medication: a ssist / self-administered Social stimulation: companionship Transportation: physician / other / ambulance / automobile Treatment: BP / pulse / respiration / temperature Unsterile dressing / ice pack / elevate feet / suction Other: Claimant Signature Caregiver Signature Date Date Supervisor Signature Date BrickStreet Mutual Insurance  P.O. Box 3151  Charleston, WV  25332-3151 American LegalNet, Inc. www.FormsWorkflow.com