Free Form 02AG030E (AG-5) - Oklahoma

*02AG030E-001*
OKLAHOMA DEPARTMENT OF HUMAN SERVICES

Personal Care Planning Schedule
Copy to: Provider/OKDHS nurse Date sent: Client Date sent: File Date sent: Client name Case number Date OKDHS or agency nurse signature

Enter an X in the check box for each task where assistance is needed. Enter number of units on the day(s) of the week the tasks will be completed by the client's chosen agency or individual provider. Enter the daily total on the bottom line of page 3 to identify the total units of service the client will receive each day. A unit is ¼ hour or 15 minutes. Personal care tasks bath assistance skin care groom oral hygiene shampoo brush/comb hair roll hair safety supervision transfer assist dress assist shave make bed dry hair oil scalp Total units per day Number of units used: Mon Tue Wed Thu Fri Sat Sun Comments

OKDHS revised 4-20-2007

02AG030E (AG-5)

Page 1 of 4

02AG030E (AG-5) Meal tasks meal preparation am noon pm advanced meal preparation am noon pm extra for weekends store foods appropriately clean kitchen and area clean appliances stove refrigerator Total units per day Number of units used: Housekeeping tasks sweep floors vacuum floors dust mop floors dustmop floors remove trash clean and tidy living room clean and tidy bedroom thoroughly clean bathroom other other Total units per day Number of units used: Laundry tasks in home laundromat apartment facility home of the personal care assistant (PCA) Total units per day Number of units used: Mon Tue Wed Mon Tue Wed Mon Tue Wed

Personal Care Planning Schedule Comments

Thu

Fri

Sat

Sun

Comments

Thu

Fri

Sat

Sun

Comments

Thu

Fri

Sat

Sun

Page 2 of 4

OKDHS revised 4-20-2007

Personal Care Planning Schedule Errand tasks groceries medications mail medical supplies Total units per day Number of units used: Specific tasks assist pay bills nail care vital signs frequent transfers spoon feed foot care weight toileting remind to take medications clean bedside commode/urinal unskilled treatments application of appliance Total units per day Number of units used: Weekly total units per day Number of units used: Total of all columns = units per week, Mon Tue Wed Thu Fri Mon Tue Wed Thu Fri Mon Tue Wed Thu Fri

02AG030E (AG-5) Comments

Sat

Sun

Comments

Sat

Sun

Sat

Sun

units per month

Identified days optional unless specified in care plan.

OKDHS revised 4-20-2007

Page 3 of 4

02AG030E (AG-5)

Personal Care Planning Schedule

Average time to complete task:
Tasks Bathing (shower, sponge, tub) Includes dressing, grooming, skin care, shampoo, hair care, oral hygiene, cleaning bath area, and making bed. Average time to complete 1 hour = 4 units Comments Baths three times a week for tub and shower. Five times a week for sponge and continually incontinent. Nail care consists of cleaning and filing only.

Grooming and dressing without a bath Includes washing face and hands, shaving, oral hygiene, combing hair, nail care, foot care, and making bed. Hair care without a bath Includes shampoo, combing, brushing, drying hair, and oiling scalp. Transfer and walking assistance Includes transferring to and from bed to chair, chair to chair, chair to toilet, transfer in or out of tub and shower, ambulating with gait belt, and stand-by assist in ambulation. Meal preparation Includes planning, preparation of a cooked meal with leftovers, cleaning area, and washing dishes. Housekeeping Includes sweeping and mopping floors, remove trash, dust, clean living room, bedroom, and bathroom. Clean bedside commode and urinal. Laundry in home and linen change Includes washing, drying, and replacing linens on bed. Laundry outside the home Includes washing, drying, folding, and return to home. Errands Includes grocery shopping, paying bills, medication pick-up, mail pickup if box not at residence. Safety supervision Safety supervision only while PCA is in home, but doing other tasks.

Half an hour = 2 units

Half an hour = 2 units 15 minutes = 1 unit

1 hour = 4 units

Home delivered meals replace one meal preparation a day.

1 hour = 4 units

1 hour = 4 units

2 hours = 8 units 1 hour = 4 units

Laundry done off site at apartment complex or laundromat. Money receipts must be maintained.

0 hours

Page 4 of 4

OKDHS revised 4-20-2007