Form 4122 April 2014-E Home and Community-based Services Host/Companion Service Delivery Log Individual Name First Last Location Local Case No./Case ID Week Of At the end of the day mark initial or check all items that you completed with the individual. If there were any incidents concerns or special events document on the bottom of the form. Sunday Monday Tuesday Wednesday Thursday Friday Saturday mm/dd/yy Activities of Daily Living Bathing Dressing Personal Hygiene Eating Meal Planning Meal Preparation Housekeeping Habilitation Develop and Improve Independent Living Skills Community Integration Develop Socially Valued Behaviors Use of Natural Supports Participate in Leisure Activities IP Skill Development Assisting With Ambulation and Mobility Administration of Medication Reinforcing Specialized Therapies Transportation Supervising Safety and Security Monitoring Health Monitoring Personal Hygiene Not in Home Temporary Discharge Active on Leave Date Initials Comments Staff ID. .
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How to fill out the TX Form 4122 online
Filling out the TX Form 4122 is an essential step in documenting the delivery of home and community-based services. This guide provides clear and succinct instructions on completing the form online, ensuring that all necessary information is accurately captured.
Follow the steps to complete the TX Form 4122 online.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by entering the individual's name in the designated fields marked 'Individual Name (First, Last)'. Ensure both names are spelled correctly.
- Input the location where the services are being provided in the 'Location' field.
- Fill in the 'Local Case No./Case ID' to correlate with the appropriate case.
- Enter the date range for service delivery in the 'Week Of' section, marking the start date.
- As you assist the individual through various activities, initial beside the corresponding daily activities under Sunday to Saturday to confirm completion.
- In case of any incidents or events during the week, use the comments section at the bottom of the form to document these occurrences.
- Make sure to complete the 'Habilitation' and 'Assisting With' sections by checking the appropriate services provided during the week.
- If the individual was not in the home, denote this by checking the box for 'Temporary Discharge' or 'Active on Leave.'
- Conclude by ensuring the 'Host Home/Companion Care Initials' and 'Printed Name' fields are filled out, along with the staff signature.
- Finally, save your changes, and you may choose to download, print, or share the completed form for your records.
Complete your TX Form 4122 online today for accurate service documentation.
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