Dhs 4691 Eng Form – Fill Out and Use This PDF

PCA AGENCY NAME

DATES/LOCATION OF RECIPIENT STAY IN HOSPITAL/CARE FACILITY/INCARCERATION

PHONE NUMBER

Dates of Service

(in consecutive order)

Activities

MM/DD/YY

MM/DD/YY

MM/DD/YY

MM/DD/YY

MM/DD/YY

MM/DD/YY

MM/DD/YY

Daily Total

(minutes)

Total Minutes This Time Sheet

MINUTES		MINUTES	MINUTES		MINUTES	MINUTES		MINUTES		MINUTES
	Total 1:1				Total 1:2				Total 1:3
MINUTES				MINUTES			MINUTES

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

Enter name of the PCA provider agency and its phone number.

Recipient Stays

Enter dates and location of recipient stays in a hospital, care facility or incarceration.

Dates of Service

Dates of service must be in consecutive order. Enter the date in mm/dd/yy format for each date you provide service. The recipient must draw a line through any dates and times PCA services were not provided.

Activities

For each date you provided care, write your initials next to all the activities you provided. Your initials indicate you provided the service as described in the PCA Care Plan. If you provide a service more than once in a day, initial only once. The following are general descriptions of activities of daily living and instrumental activities of daily living.

Dressing

Choosing appropriate clothing for the day, includes laying- out of clothing, actual applying and changing clothing, special appliances or wraps, transfers, mobility and positioning to complete this task.

Grooming

Personal hygiene, includes basic hair care, oral care, nail care (except recipients who are diabetic or have poor circulation), shaving hair, applying cosmetics and deodorant, care of eyeglasses, contact lenses, hearing aids.

Bathing

Starting and finishing a bath or shower, transfers, mobility, positioning, using soap, rinsing, drying, inspecting skin and applying lotion.

Eating

Getting food into the body, transfers, mobility, positioning, hand washing, applying of orthotics needed for eating, feeding, preparing meals and grocery shopping.

Transfers

Moving from one seating/reclining area or position to another.

Moving including assistance with ambulation, including use of a wheelchair. Mobility does not include providing transportation for a recipient.

Positioning

Including assistance with positioning or turning a recipient for necessary care and comfort.

Toileting

Bowel/bladder elimination and care, transfers, mobility, positioning, feminine hygiene, use of toileting equipment or supplies, cleansing the perineal area and inspecting skin and adjusting clothing.

Health-related Procedures and Tasks

Health related procedures and tasks according to PCA policy. Examples include: range of motion and passive exercise, assistance with self-administered medication including bringing medication to the recipient, and assistance with opening medication under the direction of the recipient or responsible party, interventions, monitoring and observations for seizure disorders, and other activities listed on the care plan and considered within the scope of the PCA service meeting the definition of health-related procedures and tasks.

Behavior

Redirecting, intervening, observing, monitoring and documenting behavior.

IADLs (Instrumental Activities of Daily Living)

Covered service for recipients over age 18 years only, such as: meal planning and preparation, basic assistance with paying the bills, shopping for food, clothing, and other essential items, performing household tasks integral to the personal care assistance services; assisting with recipient’s communication by telephone, and other media, and accompanying the recipient with traveling to medical appointments and participation in the community.

Visit One

Documentation of the first visit of the day.

Ratio of PCA to Recipient

1:1 = One PCA to one recipient

1:2 = One PCA to two recipients (shared services) 1:3 = One PCA to three recipients (shared services)

Circle the appropriate ratio of PCA to recipients for this visit.

Visit Two

Documentation of the second visit of the day.

Ratio of PCA to Recipient

1:1 = One PCA to one recipient

1:2 = One PCA to two recipients (shared services) 1:3 = One PCA to three recipients (shared services)

Circle the appropriate ratio of PCA to recipients for this visit.

Shared Services Location

(Required for shared services only) Write a brief description of the location where you provided the shared services, examples include school, work, store and home.

Time in

Enter time in hours and minutes that you started providing care and circle AM or PM.

Time out

Enter time in the hours and minutes that you stopped providing care and circle AM or PM.

Daily Total

Add the total time in minutes that you spent with this recipient for the care documented in one column.

Total Minutes This Time Sheet

Add the time in minutes for all visits on this entire time sheet and enter the total in the appropriate ratio box.

Acknowledgement and Required Signatures

Recipient/responsible party prints the recipient’s first name, middle initial, last name, and MA Member (MHCPID) Number or birth date (for identifying purposes). Recipient/ responsible party signs and dates form. PCA prints his/ her first name, middle initial, last name, individual

PCA Unique Minnesota Provider Identifier (UMPI) (for identifying purposes). PCA signs and dates form.

Atención. Si desea recibir asistencia gratuita para interpretar este documento, llame al número indicado arriba.

Chú ý. Nếu quý vị cần được giúp đỡ dịch tài liệu này miễn phí, xin gọi số bên trên.

LB3-0001 (3-13)