DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1152A (02/09)
STATE OF WISCONSIN
PERSONAL CARE WORKER DAILY RECORD OF CARE COMPLETION INSTRUCTIONS
ForwardHealth requires certain information to enable the programs to authorize and pay for medical services provided to eligible members. Under s. 49.45(4), Wis. Stats., personally identifiable information about program applicants and members is confidential and is used for purposes directly related to ForwardHealth administration such as determining eligibility of the applicant, processing prior authorization (PA) requests, or processing provider claims for reimbursement. Failure to supply the information requested by the form may result in denial of PA or payment for the service. The use of this form is voluntary, and providers may develop their own form as long as it includes all the information on this form. Name -- Member Enter the member's name. (A record of care must be filled out for each member the PCW cares for in the residence). Member Identification Number (Optional) Provider may enter the member's identification number or an internal identifying number. Date Enter the date (month/day/year) service was provided. NAME(S) -- Personal Care Worker (PCW) Enter the name of each PCW in a separate column. START TIME Enter the time personal care begins. END TIME Enter the time personal care ends. ADDITIONAL TASKS Enter the time spent providing Medicaid-funded tasks only. To document the time spent, PCWs may choose any of the following: Enter check mark(s) for each task provided. Enter the time (in minutes) actually spent providing each task. Enter the time each task was started and ended. Medicaid reimburses only one PCW to perform a task for a member, except for prior authorized two-person transfers. If a supervisor chooses to direct workers to share tasks, only the worker who is primarily responsible may record the task and the total amount of time spent by all workers on that task. If a housekeeping task benefits more than one member, the total unduplicated time reported must be divided amount the members who benefit. INDIVIDUAL PCW TOTAL TIME PCW INITIALS Each PCW should initial his or her column on the form. TOTAL -- ALL MEDICAID HOURS At the end of each day, each PCW should enter the total amount of time spent providing Medicaid-covered services on that date of service. The PCW must record the total time actually spent for Medicaid-covered tasks, not time estimated by the agency or on the prior authorization. MEMBER SIGNATURE Member signs and dates the form. If the member does not sign the record of care, the agency must document in the medical record why not.
PERSONAL CARE WORKER WEEKLY RECORD OF CARE COMPLETION INSTRUCTIONS F-1151A (02/09)
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COMMENTS Enter any comments about the member's condition. Always document reason(s) for changes in the time it takes to provide care. Date and initial each notation. Examples include: General comments. Changes in member's condition. Emergency hours. Refusal of care. Institutional admission and discharge, including time of admission or discharge and time of cares given. PERSONAL CARE WORKER SIGNATURE(S) Each PCW signs and dates the form. REGISTERED NURSE SUPERVISOR SIGNATURE The RN supervisor signs and dates the form.