A 3-page printable Word chart for caregivers to record medication reminders given during the week.

For USA non-medical home care agency owners and supervisors where caregivers give reminders only. Plus 1 agency instructions page to remove before use.

What’s included

1. Page 1: client, week, pharmacy and office phones, medication list as on the pharmacy label, and list changes (office updates only)
2. Page 2: weekly reminder grid with initials and the missed / refused report log
3. Page 3: initials key, caregiver list, when to call the office, supervisor weekly review, and Agency Use Only
4. Agency instructions page, to remove before use

Add your logo and name

1. Open the Word file and replace the Your Logo Here box with your logo.
2. Replace Agency Name in the letterhead; the body says “the Agency,” so no other name edits are needed.
3. Replace the Street Address, City, State ZIP line and the Phone, Email, Website line with your details.
4. Set the letterhead text to black, delete the instructions page, and save.

Customizable template, not legal advice; check your state’s requirements. Not a license to operate, not HIPAA software, and no medical claims. Reminders only: caregivers do not handle or give medication. This chart records reminders; it is not medical advice.