Monthly Care Summary

Virginia Birth-Related Neurological Injury Compensation Program

Monthly Care Summary

(Must be submitted at the end of each month with timesheets)

Please check the appropriate box:*

Family CaregiverIndependent Caregiver

Email for Person Completing this Form*

example@example.com

General Information:

Month*

Year*

Claimant's Name*

Example: John Smith

Caregiver Name*

Relation (make 1 selection)*

Physician's Name*

Phone*

List medications and times given: (Only list each medication once and the time(s) of day normally given. This is not a daily list, just a general description of medications and times given.)

To start--> Start typing on the open spaces in this table to start listing each medication. If you need more space for any category, please attached a second page (Upload in the Add Files here through drag/drop or Upload from your computer or portable device).

	.	.	.
1
2
3
4

Personal care given (checkbox, circle method or fill in the blank):

	In bed	In tub	In shower
Bathing:

	By mouth	By tube
Feeding:

Pediasure (or other) #cans/day

Enter a numerical value

Type of brand

Example: Pediasure, Kate Farms, Nutramagen, Neocate, etc.

	Passed urine	Has catheter in place
Toileting:

	Yes	No
Mouth/Teeth Care:

	Yes	No
Turning Exercise arms and legs every day:

Every enter a number* hours

Status:

	Yes	No
Bowel Movement:

Skin Condition:

Good or red areas - location*

If not applicable, write N/A

Sore open areas - location

If not applicable, write N/A

List of equipment being used:

	.	.
1
2
3

If you need more space for any category above, please attach (upload) a second page. Upload the document in PDF(scanned file) or JPG (photo image) into the link below. Any comments for Nurse Case Manager?

Caregiver Signature*

Date

Submit Instructions: To finalize your submission, you have three options.

1 - Preview PDF - Review the draft version and save as a PDF or print a copy.

2. Save and Continue Later - Save your draft submission for up to 90 days. Once you click this button, you will receive an email with a link to return at a future time.

3. Submit - Click this button if you are ready to submit.