Fillable Dhs-4691-Eng - Dhs Pca Time And Activity Documentation (Page 2 of 3) in pdf

Daily Total

MINUTES

(minutes)

Total Minutes

Total 1:1

Total 1:2

Total 1:3

This Time Sheet

MINUTES

Acknowledgement and Required Signatures

After the PCA has documented his/her time and activity, the recipient must draw a line through any dates and times he/

she did not receive services from the PCA. Review the completed time sheet for accuracy before signing. It is a federal crime

to provide false information on PCA billings for Medical Assistance payment. Your signature verifies the time and services

entered above are accurate and that the services were performed as specified in the PCA Care Plan.

RECIPIENT NAME (FIRST, MI, LAST)

MA MEMBER # or DATE OF BIRTH RECIPIENT/RESPONSIBLE PARTY SIGNATURE

DATE

PCA NAME (FIRST, MI, LAST)

PCA NPI/UMPI

PCA SIGNATURE

DATE

Instructions for

PCA Time and Activity Documentation

This form documents time and activity between one PCA and one recipient. Document up to two visits per day on

this form. Employers may have additional instructions or documentation requirements. For shared care, you must

use a separate form for each person for whom you are providing care.

Name of PCA Provider Agency

general descriptions of activities of daily living and

instrumental activities of daily living.

Enter name of the PCA provider agency and its

telephone number.

Dressing

– Choosing appropriate clothing for the

day, includes laying-out of clothing, actual applying

Recipient Stays

and changing clothing, special appliances or wraps,

transfers, mobility and positioning to complete this

Enter dates and location of recipient stays in a

task.

hospital, care facility or incarceration.

Grooming

– Personal hygiene, includes basic hair

Dates of Service

care, oral care, nail care (except recipients who

are diabetic or have poor circulation), shaving

Dates of service must be in consecutive order. Enter

hair, applying cosmetics and deodorant, care of

the date in mm/dd/yy format for each date you

eyeglasses, contact lenses, hearing aids

provide service. The recipient must draw a line

through any dates and times PCA services were not

Bathing

– Starting and finishing a bath or shower,

provided.

transfers, mobility, positioning, using soap, rinsing,

drying, inspecting skin and applying lotion.

Activities

Eating

– Getting food into the body, transfers,

For each date you provided care, write your initials

mobility, positioning, hand washing, applying of

next to all the activities you provided. Your initials

orthotics needed for eating, feeding, preparing

indicate you provided the service as described in the

meals and grocery shopping.

PCA Care Plan. If you provide a service more than

Transfers

– Moving from one seating/reclining area

once in a day, initial only once. The following are

or position to another.

Dhs-4691-Eng - Dhs Pca Time And Activity Documentation Page 2

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