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

Visit One

Mobility

– Moving including assistance with

ambulation, including use of a wheelchair. Mobility

Documentation of the first visit of the day.

does not include providing transportation for a

Ratio of PCA to Recipient –

recipient.

1:1 = One PCA to one recipient

Positioning

– Including assistance with positioning

1:2 = One PCA to two recipients (shared services)

or turning a recipient for necessary care and

1:3 = One PCA to three recipients (shared services)

comfort.

Circle the appropriate ratio of PCA to recipients

Toileting

– Bowel/bladder elimination and care,

for this visit

transfers, mobility, positioning, feminine hygiene,

Shared Care Location

– (Required for shared care

use of toileting equipment or supplies, cleansing

only) Write a brief description of the location where

the perineal area and inspecting skin and adjusting

you provided the shared care, examples include

clothing.

school, work, store and home.

Health-related Procedures and Tasks

– Health

Time in

– Enter time in hours and minutes that you

related procedures and tasks according to PCA

started providing care and circle AM or PM.

policy. Examples include: range of motion and

passive exercise, assistance with self-administered

Time out

– Enter time in the hours and minutes that

medication including bringing medication to the

you stopped providing care and circle AM or PM.

recipient, and assistance with opening medication

under the direction of the recipient or responsible

Visit Two

party, interventions, monitoring and observations

This is documentation for the second visit of the day.

for seizure disorders, and other activities listed on

Follow instructions for Visit One above.

the care plan and considered within the scope of the

PCA service meeting the definition of health-related

Daily Total

procedures and tasks.

Add the total time in minutes that you spent with this

Behavior

– Redirecting, intervening, observing,

recipient for the care documented in one column.

monitoring and documenting behavior.

IADLs (Instrumental Activities of Daily Living)

–

Total Minutes This Time Sheet

Covered service for recipients over age 18 years

Add the time in minutes for all visits on this entire

only, such as: meal planning and preparation,

time sheet and enter the total in the appropriate

basic assistance with paying the bills, shopping

ratio box.

for food, clothing, and other essential items,

performing household tasks integral to the personal

Acknowledgement and Required

care assistance services; assisting with recipient’s

Signatures

communication by telephone, and other media,

and accompanying the recipient with traveling to

Recipient/responsible party prints the recipient’s first

medical appointments and participation in the

name, middle initial, last name, and MA Member

community.

(MHCPID) Number or birth date (for identifying

purposes). Recipient/responsible party signs and

Light Housekeeping

– Light housekeeping integral

dates form. PCA prints his/her first name, middle

to personal care may include washing dishes,

initial, last name, individual PCA Unique Minnesota

putting dishes in dishwasher, clearing tables,

Provider Identifier (UMPI) (for identifying purposes).

taking out garbage, making the bed and cleaning

PCA signs and dates form.

bathroom.

Laundry

– Laundry integral to personal care,

includes sorting clothes, putting clothes in washer

and dryer, adding soap and/or dryer sheet, folding

and putting away clothes.

Other

Dhs-4691-Eng - Dhs Pca Time And Activity Documentation Page 3

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