Free Form 02AG030E (AG-5) - Oklahoma

Personal Care Planning Schedule Purpose of form

02AG030E (AG-5)

Form 02AG030E is completed by the OKDHS nurse or provider agency nurse as an aid in personal care (PC) plan development and in establishing the number of units required for task completion. Instructions Enter an X in the check box for each task where assistance is needed. Enter the number of units on the day(s) tasks will be completed by the client's chosen agency or individual provider. Use comment boxes to clarify as needed. Enter the daily total on page 3 to identify the total units of service the client will receive each day. A unit is ¼ hour or 15 minutes. Time allotment considerations: The amount of time for each task will depend on the: · · · · · needs of the client, and the ability and cooperation of client and the client's family; use of assistive devices and the availability of other persons to assist with the required tasks; availability of equipment and supplies to complete the task; clustering of some tasks into the same time frame; and tasks already being performed by the formal or informal caregiver. Routing Original - OKDHS nurse case file or provider agency file Copy - agency provider or individual provider Copy - client

OKDHS revised 4-20-2007

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