Free Form 02AG040E (AG-22-A) Instructions - Oklahoma

Personal Care Assistant (PCA) Supervisory Visit Purpose of form

02AG040E (AG-22-A)

Form 02AG040, Personal Care Assistant (PCA) Supervisory Visit, is used by the Long-Term Care Authority certified provider agencies to document supervisory PCA visits. Instructions Client: Enter the client's name. Case number: Enter the client's Medicaid number. Date: Enter the date the supervisory visit was made. Routine supervisory visit: Check yes if the visit is routine. Check no if it is not routine. Agency: Enter the provider agency name. Aide present: Check yes or not to indicate if the PCA was there or not.

Client review.
1. Check the choice that corresponds with the client's answer. 2. Check the choice that corresponds with client's answer. Enter client's comments. 3. Check the choice that corresponds with the client's answer. Enter the client's comments. 4. Check the choice that corresponds with the client's answer. 5. Enter the client's response. 6. Check the choice that corresponds with the client's answer. Enter the client's comments, if required.

Supervisor review:
Enter the client's name and case number. Questions 1-5. Check the choice corresponding with the client's response and enter comments, if required. Clients signature: Signature of the client. Nurses signature: Signature of the nurse completing the 02AG040E. PCA signature: Signature of the PCA, if present during the supervisory visit. Routing The original Form 02AG040E is kept in the client`s record at the provider agency. A copy of Form 02AG040E is sent to the LTC (DHS) Nurse Case Manager and kept in the client's personal care record.

Issued 5-15-2001

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