DHS -4 6 9 1 -EN G
9 -1 1
PCA Time and Activity Documentation
PCA AGENCY NAME
PHONE NUMBER
V-Care Home Health, Inc.
( 651 ) 793 - 7635
DATES/LOCATION OF RECIPIENT STAY IN HOSPITAL/CARE FACILITY/INCARCERATION
INDIVIDUAL PCA PROVIDER NAME
Dates of
Service
RECIPIENT NAME
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
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Dressing
Grooming
Bathing
Eating
Transfers
Mobility
Positioning
Toileting
Health Related
Behavior
IADLs
Meal Preparation
Light House Keeping
Laundry
Grocery Shopping
Medical Appointments
Participate in Community
Blood Sugar\Blood Pressure
Reminder of Medication Intake
Visit One
Ratio staff to recipient
Sunday
1:1
1:2
Monday
1:3
1:1
1:2
Tuesday
1:3
1:1
1:2
Wednesday
1:3
1:1
1:2
1:3
Thursday
1:1
1:2
Friday
1:3
1:1
1:2
Saturday
1:3
1:1
1:2
1:3
Shared services location
Time in
AM
(check AM/PM)
PM
PM
PM
PM
PM
PM
PM
Time out
AM
AM
AM
AM
AM
AM
AM
PM
PM
PM
PM
PM
PM
PM
(check AM/PM)
Page 1 of 4
AM
AM
AM
AM
AM
AM
MR#
Visit Two
Ratio staff to recipient
Sunday
1:1
1:2
Monday
1:3
1:1
1:2
Tuesday
1:3
1:1
1:2
Wednesday
1:3
1:1
1:2
1:3
Thursday
1:1
1:2
Friday
1:3
1:1
1:2
Saturday
1:3
1:1
1:2
1:3
Shared services location
Time in
AM
(check AM/PM)
PM
PM
PM
PM
PM
PM
PM
Time out
AM
AM
AM
AM
AM
AM
AM
PM
PM
PM
PM
PM
PM
PM
(check AM/PM)
AM
AM
AM
AM
AM
AM
Recepient/Responsible
Party Initial
Daily Total
MINUTES
Total Minutes
This Time Sheet
MINUTES
MINUTES
MINUTES
MINUTES
MINUTES
MINUTES
MINUTES
(minutes)
Total 1:1
Total 1:2
MINUTES
Total 1:3
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
PCA Comment
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Page 2 of 4
MR#
DHS-4691-ENG 9-11
Review PCA Provider Time and Activity Documentation for additional policy information about timesheet requirements.
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
Enter name of the PCA provider agency and its telephone
number.
Recipient Stays
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.
Enter dates and location of recipient stays in a hospital,
care facility or incarceration.
Behavior Redirecting, intervening, observing,
monitoring and documenting behavior.
Dates of Service
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 recipients
communication by telephone, and other media, and
accompanying the recipient with traveling to medical
appointments and participation in the community.
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.
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.
Mobility 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
Page 3 of 4
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.
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)
Check 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.
MR#
DHS-4691-ENG 9-11
Time in Enter time in hours and minutes that you
started providing care and check AM or PM.
Time out Enter time in the hours and minutes that you
stopped providing care and check AM or PM.
Visit Two
This is documentation for the second visit of the day. Follow
instructions for Visit One above.
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
Relationship
Indicate the relationship of the individual PCA provider to
the recipient.
Acknowledgement and Required
Signatures
Recipient/responsible party prints the recipients 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.
Add the time in minutes for all visits on this entire time
sheet and enter the total in the appropriate ratio box.
This information is available in alternative formats to individuals with disabilities by calling your PCA provider agency. TTY users
can call through Minnesota Relay at (800) 6273529. For Speech-to-Speech, call (877) 6273848. For additional assistance with
legal rights and protections for equal access to human services programs, contact your agencys ADA coordinator.
Page 4 of 4
MR#
DHS-4691-ENG 9-11
