DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1151A (02/09)
STATE OF WISCONSIN
PERSONAL CARE WORKER WEEKLY 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. NAME -- EMPLOYEE Enter the name of the personal care worker (PCW) providing care. (Each PCW caring for a member needs to complete a separate record of care.) YEAR Enter the year personal care services are provided. MEMBER IDENTIFICATION NUMBER (OPTIONAL) Provider may enter the member's identification number or an internal identifying number. DATE OF SERVICE Enter the month and date (month/day) of each date of service. 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. If two or more tasks are performed simultaneously (e.g., laundry and meal preparation), total time recorded for those tasks cannot exceed the total unduplicated time spent performing them. TOTAL MEDICAID TIME Each day, 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. 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 WEEKLY RECORD OF CARE COMPLETION INSTRUCTIONS F-1151A (02/09)
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TRAVEL TIME To enter travel time, choose one of the following: Check the box provided if using a computer-generated itinerary. Complete the chart in entirety if: Deviating from the computer-generated itinerary. Not using a computer-generated itinerary. When a PCW changes the routine itinerary, either a new itinerary must be documented or the PCW must complete the travel time chart on the record of care form. If a computer-generated method is used, the provider must maintain the following information on file in the agency records: The computer-generated map documenting the shortest time between travel locations. The routine itineraries for each PCW. The address of locations for which "to" and "from" travel occurs. The member's name and address. The dates of service, start and end times, and personal care services provided. PERSONAL CARE WORKER SIGNATURE The PCW signs and dates the form. REGISTERED NURSE SUPERVISOR SIGNATURE The RN supervisor signs and dates the form.