Dhs-4691-Eng - Dhs Pca Time And Activity Documentation

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Clear Form Data
FILLABLE FORM
*DHS-4691-ENG*
DHS-4691-ENG
1-10
PCA Time and Activity Documentation
PCA AGENCY NAME
PHONE NUMBER
(
)
DATES/LOCATION OF RECIPIENT STAY IN HOSPITAL/CARE FACILITY/INCARCERATION
Dates of Service
MM/DD/YY
MM/DD/YY
MM/DD/YY
MM/DD/YY
MM/DD/YY
MM/DD/YY
MM/DD/YY
(in consecutive order)
Activities
Dressing
Grooming
Bathing
Eating
Transfers
Mobility
Positioning
Toileting
Health Related
Behavior
IADL’s (only recipients age18+)
Light Housekeeping
Laundry
Other
Visit One
Ratio staff to recipient
1:1
1:2
1:3
1:1
1:2
1:3
1:1
1:2
1:3
1:1
1:2
1:3
1:1
1:2
1:3
1:1
1:2
1:3
1:1
1:2
1:3
Shared care location
AM
AM
AM
AM
AM
AM
AM
Time in
(circle AM/PM)
PM
PM
PM
PM
PM
PM
PM
AM
AM
AM
AM
AM
AM
AM
Time out
(circle AM/PM)
PM
PM
PM
PM
PM
PM
PM
Visit Two
Ratio staff to recipient
1:1
1:2
1:3
1:1
1:2
1:3
1:1
1:2
1:3
1:1
1:2
1:3
1:1
1:2
1:3
1:1
1:2
1:3
1:1
1:2
1:3
Shared care location
AM
AM
AM
AM
AM
AM
AM
Time in
(circle AM/PM)
PM
PM
PM
PM
PM
PM
PM
AM
AM
AM
AM
AM
AM
AM
Time out
(circle AM/PM)
PM
PM
PM
PM
PM
PM
PM
1

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