Free Form 02AG029E (AG-4) Instructions - Oklahoma

Personal Care Plan Purpose of form Form 02AG029E is used to document: · · ·

02AG029E (AG-4)

a program of action; implementation of alternatives to reach desired outcomes; and the progress toward meeting the goals agreed upon by the client in his or her service plan. This form must be amended as the client's conditions change. Instructions

Enter each objective. These should have a specific time frame, from six months to three years. Enter the action steps required to meet each objective. Enter the measurable expected outcomes that will result from the implementation of these action steps. Enter follow-up comments or information regarding the goal being met or why it was not met in the follow-up block after each visit or when changes occur. Enter date the Personal Care Plan was reviewed, revised, services continued through, and the signature of the client, OKDHS nurse, and informal support person. Informal support is given by persons who provide unpaid caregiving, such as son, daughter, friend, or neighbor. Routing Original forwarded along with Form 02AG031E, Personal Care (PC) Service Plan, to the OKDHS area nurse for certification; filed in OKDHS nurse client case record after approval agency or individual provider client

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Revised 1-1-2005

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