Free ADL Checklist for Home Care Visits (Printable)
A printable ADL and IADL checklist caregivers complete each visit, with assistance levels, a change-in-condition box, and notes on how to use it.
By Caregiver Scheduling Team ·
This checklist lets a caregiver record, on one page per visit, which activities of daily living (ADLs) and instrumental activities (IADLs) they helped with and how much help the client needed. Print it, use one sheet per visit, and file it with the care plan. The template is below, followed by notes on how to fill it in and what to do with it.
Client: ____________ Caregiver: ____________ Date: ________ Time in: ______ Time out: ______
Assistance levels: I = independent, S = standby / cueing, P = partial hands-on help, F = full help, R = refused, N/A = not in care plan
Activities of daily living (ADLs)
| Activity | Level | Notes |
|---|---|---|
| Bathing / shower | ||
| Dressing | ||
| Grooming (hair, teeth, shaving) | ||
| Toileting | ||
| Continence care | ||
| Transferring (bed, chair) | ||
| Walking / mobility | ||
| Eating |
Instrumental activities (IADLs)
| Activity | Done? | Notes |
|---|---|---|
| Meal preparation | ||
| Light housekeeping | ||
| Laundry | ||
| Medication reminder (not administration) | ||
| Errands / shopping | ||
| Transportation / escort | ||
| Companionship / activities |
Changes to report to the office today
☐ Fall or near-fall ☐ New pain ☐ Skin change or redness ☐ Confusion or mood change ☐ Not eating or drinking ☐ Refused care ☐ Other: ____________
Caregiver signature: ____________
What counts as an ADL and what counts as an IADL?
ADLs are the basic personal tasks of everyday life. IADLs are the household tasks that let someone keep living at home. The federal Administration for Community Living lists six ADLs: bathing, dressing, using the toilet, transferring to or from a bed or chair, caring for incontinence, and eating. Its IADL list covers housework, managing money, taking medication, preparing and cleaning up after meals, shopping, using the telephone, caring for pets, and responding to emergency alerts.
The template adds walking and grooming to the ADL table because most care plans and state assessment tools track them separately. If your state’s assessment uses a different list, change the rows to match it.
Why record an assistance level instead of a checkmark?
Because a checkmark says the task happened, while the level shows whether the client is getting better or worse. A client who moved from standby to partial help with transfers over three weeks is telling you something a checkmark never would. Payers care too. Medicaid personal care services are furnished under a plan of treatment or state-approved service plan (42 CFR 440.167), and the plan describes a level of need. Your visit record should show that the care delivered matched it.
Keep the scale short. Six values fit on one line and caregivers remember them.
How do I use the checklist on each visit?
Complete it before leaving the home, in ink, with a signature. Here is the routine that works.
| Step | When | Who |
|---|---|---|
| Fill in client, caregiver, date and time in | On arrival | Caregiver |
| Mark each ADL and IADL with a level or Done | During or right after each task | Caregiver |
| Tick any change in condition and call the office | Before leaving | Caregiver |
| Record time out and sign | Before leaving | Caregiver |
| Review for missing rows and reported changes | Same day | Scheduler or supervisor |
| File with the care plan | Weekly | Office |
Blank rows are the most common audit finding. Every row in the care plan needs a level, a Done, or an N/A. “Refused” is a valid entry and should be written down, not left blank.
What should the caregiver do when a box in the change section is ticked?
Call the office the same day. A ticked box is a flag, not a complete report. The office decides whether to notify the family, the nurse or the physician, and whether an incident report is needed. See home care incident report for when a change becomes an incident.
Can caregivers help with medication on this checklist?
Only as a reminder, unless your state and the caregiver’s training allow more. The template says “medication reminder (not administration)” on purpose. Rules on handing over, opening or administering medication vary by state and by the caregiver’s credential. See can caregivers give medication before adding anything else to that row.
How long do I keep completed sheets?
As long as your state licensing rule and payer contracts require, with the client’s record. See home care record retention and ADL documentation in home care.
How Caregiver Scheduling handles this
The caregiver app shows each visit’s tasks from the client’s care plan. At the end of the visit, the caregiver taps the tasks done or talks through the visit, and the app fills in the task checklist and writes a short note for the caregiver to review and sign. Falls, new pain, refused meals or medications and anything else the caregiver flags go to the office as soon as the note is signed. $199/month for up to 10 caregivers or $299/month for up to 50, free for 30 days.
FAQ
Is this ADL checklist free to use? Yes. Print it, copy the tables into your own form, or adapt the rows to your state’s assessment.
How many ADLs are there? The Administration for Community Living lists six: bathing, dressing, toileting, transferring, continence care and eating. Many care plans add walking and grooming.
What if the client refuses care? Mark the row R for refused and write a short note. Never leave the row blank.
This article is general information, not legal advice. Check your state’s documentation and medication rules.