Nurses Direct, LLC
109 South College Rd - Lafayette, LA 70503
Nurse's Name
*
First Name
Last Name
Employee personal email
*
example@example.com
Home Health / Hospice shift worked:
*
St. Joseph Hospice
Private Duty
Other
Staff Type:
*
RN
LPN
CNA
Hospice shift:
*
Hospice Home visit
Hospice Office Meeting
Weekday On Call
Weekend On Call
Hospice Visit type:
Admit
Discharge
Routine
RN Home Health visit:
*
Routine Visit
Skilled nursing visit
Admit
Discharge
Re-certification
Resumption of care
ON CALL (Weekday)
ON CALL (Weekend)
Office visit/meeting
Patient not home
LPN Home Health visit type:
*
Skilled nursing visit
Office visit/meeting
Patient not home
Date worked:
*
-
Month
-
Day
Year
Date
Time arrived at home or office
*
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Hour
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Minutes
1
Office meeting / Training today?
*
YES
No
Office Meeting / Training Time In - Out
*
1
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12
:
Hour
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Minutes
AM
PM
AM/PM Option
Until
until
1
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12
:
Hour
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Minutes
AM
PM
AM/PM Option
Miles driven today:
*
Initials of each patient seen today (first letter of each first and last name):
*
Separate each patient with a comma
Patients Name
*
Miles driven per patient:
*
Miles driven from each home to home. Or from office to first home and last home to Office.
Care Provided
*
Please list care provided for patient during home visit.
Time During Home Visit
*
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01
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:
Hour
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59
Minutes
Until
until
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01
02
03
04
05
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:
Hour
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Minutes
2
I understand that ALL charting for ALL patients seen on this date of service must be completed prior to being paid for any work done on this date of service.
*
YES
NO
Nurses Direct Staff Signature
*
Submit
Should be Empty: