Independence Plus, Inc. - Time Card

Time Card

Instructions For PCA Time and Activity Documentation

This Time card has two sides Week 1 on one side and Week 2 on the back be sure you put the dates on the right side and fill out correctly.

Make sure you have these listed below correct on your timecard for faster processing.
Current Phone Number on top
Eligible Name (Employee name, dates, signatures)
SS Number
Dates of Hospitilization, Jail, and Institutionalizations
Correct Pay Period Dates
Daily Dates, and Client/Responsible Party Daily Initials
Lines through non working days
Time in and Out
Circling of AM/PM
Correct daily Hrs
Incident Reports (If applicable)
Correct work Hrs.
Initial Daily Activities (Employee)
Correct Pay Period Hrs
Client Signature/Date/Date of Birth
Employee #/Signature/Date
Total Hrs of all time Sheets
No Overlaping of time between Clients (If working with more than one Recipient)
Follow Care Plan

This form documents time and activity between one PCA, Homemaker, Chore or Respite Provider and one recipient.

Document up to three regular PCA visits per day.

This form is not to be used for shared care.

Dates of Service:

In order for the time card to be valid you Must 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 the services were not provided.

Dressing-Appropriate clothing for the day, includes laying-out of clothing, actual applying and changing clothing, orthotics, prosthetics, transfers, Mobility and positioning to complete this task

Grooming- Personal hygiene, includes hair care, oral care, nail care, shaving, applying cosmetics and deodorant, care of eyeglasses, contact lens, hearing aids and applying orthotics.

Bathing-Starting and finishing a bath or shower, transfers mobility, positioning, using soap, rinsing, drying, inspecting of skin 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 an other.

Mobility-Moving from one place to another including using a wheelchair.

Positioning-Moving the persons body for necessary care and comfort or to relieve pressure areas.

Toileting-Bowel/bladder elimination and care, transfers, mobility, positioning, feminine hygiene, using the toileting equipment or supplies, cleansing the perineal areas and inspecting skin and adjusting clothing.

Light Housekeeping-Light housekeeping may include washing dishes, putting dishes in dishwasher, clearing tables, taking out garbage, making bed and cleaning bathroom. This may also include vacuuming, sweeping, and mopping of floors. This is used for Homemaker services.

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.

Health-related Functions-Hands on assistance, supervision and cueing for health related task under the direction of a Qualified Professional or the person’s physician.

Behavior-Redirecting, intervening, observing, monitoring and documentation of behavior.

Chore-This is a service in which a client must be pre-approved for before doing this activity.

Respite-This is a service in which the client must be pre-approved for before doing this activity.

Other-Other activities performed in the care plan or other services on a service agreement by DHS that are not listed in the activity list.

Visit One:Put your 1st visit of the day with your Client.

Time In:Enter time in Hours and Minutes ( rounding to the nearest quarter hour) and circle AM or PM.

Time Out:Enter time in hours and minutes (rounding to the nearest quarter hour) that you stopped providing care and circle AM or PM.

Visit two-
If you return to your client for a second visit that day put you time in and time out here.

Visit Three-If you return to your client for a third visit that day put you time in and time out here.

Visit 4th Late PCA- This section is never to be used

Chore- You must never put anything here unless Social Services has screened your client for Chore service an approved them.

Respite- You must never put anything here unless Social Services has screened your client for Respite services and approved them.

Clients intial Daily- The Client must intial here everyday or the PCA will not be paid.By initialing this the client is verifying that the PCA has completed the task marked for that day.

Total Daily Time- Add the total time in hours and minutes (rounding to the nearest quarter hour) that you spent with your client for the care documented in one column.

Total Week 1-add all daily hours and minutes ( round off to the nearest quarter hour) and write in Week 1

Total Week 2- add all daily hours and minutes ( round off to the nearest quarter hour) and write in Week 2

Total Time Both Sides- add both week 1 and week 2 totals together and put the total in the Total Time Both Sides box.

PCA Time Card (PDF)

Contact

27885 170th Ave. SW
Crookston, MN 56716-9444
Ph: (218) 281-3506
Fax: (218)281-3015
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