Timesheet

Timesheet

4807 Jonestown Rd #149, Harrisburg, PA 17109 Phone: 717-210-3153 Fax: 717-547-9378 Email: harrisburg@namsarahomecare.com TIN # 472122807 AmeriHealth ID: 30789023 UPMC ID: 441903 PA Health & Wellness ID: 2519962
Employee (DCW) Full Name*

First NameLast Name
Employee's Last 4 of Social Security #*
Consumer's Full Name*

First NameLast Name
Address of Service*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Name*

AmeriHealth CaritasUPMCPA Health and Wellness
Insurance ID #*
Date of Service*

MonthDayYear
Date
Start Time*

Hour Minutes

AM/PM Option
End Time*

Hour Minutes

AM/PM Option
Total Hours*
What you missed?*

Clock-In MissedClock-Out missedBoth Clock-In and Clock-Out missedClock-In or Clock-Out Early or LateOther
Reason*

Forgot to either Clock-In or Clock-Out or BothHHA app down or internet problemPhone problem or technical issueConsumer received service outside of homeOther
Duty Codes (AmeriHealth Caritas)

115 Meal Preparation116 Housework/Chore117 Managing Finances118 Managing Medications119 Shopping120 Transportation122 Hygiene123 Dressing Upper124 Dressing Lower125 Locomotion126 Transfer127 Toilet Use128 Bed Mobility129 Eating130 Bladder Incontinence131 Bowel Incontinence132 Personal Care T1019134 Bathing137 Lotion/Ointment138 Laundry139 Reading/Writing140 Supervision/Coaching/Cueing141 Incontinence Care201 In Person202 Via Telephone203 Other204 Bath-Tub205 Bath Shower206 Phone Use207 Patient Requires Total Care208 Mouth Care/Denture Care209 Hair Care-Comb210 Grooming-Shave212 Grooming-Nails213 Dressing214 Skin Care215 Foot Care216 Toiletting Diaper217 Toileting Commode218 Toileting Bedpan/Urinal220 Patient is on prescribed diet221 Prepare Breakfast222 Prepare Lunch223 Prepare Dinner224 Prepare Snack225 Assist with Feeding226 Record Intake-Food227 Record Intake-Fluid228 Transferring229 Assist with walking230 Patient walks with assistive devices231 Assist with home exercise program232 Range of motion exercises233 Turning and positioning (At least Q2)235 Take temperature236 Take pulse237 Take blood pressure238 Weigh patient239 Take respirations246 Medication Reminders247 Change Bed linen249 Light Housekeeping250 Clean bathroom251 Clean patient care equipment252 Do patient shopping and errands253 Accompany patient to medical appointment254 Accompany patient on errands255 Diversional activities-Speak/Read256 Assist with exercises257 Monitor patient safety262 Fall risk precautions263 Choke Risk Precautions264 Seizure Precautions265 Safe Transfer Precautions
Duty Codes (UPMC)

115 Meal Preparation116 Housework/Chore117 Managing Finances118 Managing Medications119 Shopping120 Transportation122 Hygiene123 Dressing Upper124 Dressing Lower125 Locomotion126 Transfer127 Toilet Use128 Bed Mobility129 Eating145 Stairs130 Bladder Incontinence131 Bowel Incontinence132 Personal Care T1019134 Bathing137 Lotion/Ointment138 Laundry139 Reading/Writing140 Supervision/Coaching/Cueing141 Incontinence Care201 In Person202 Via Telephone206 Phone Use
Duty Codes (PA Health and Wellness)

115 Meal Preparation116 Housework/Chore117 Managing Finances118 Managing Medications119 Shopping120 Transportation122 Hygiene123 Dressing Upper124 Dressing Lower125 Locomotion126 Transfer127 Toilet Use128 Bed Mobility129 Eating130 Bladder Incontinence131 Bowel Incontinence132 Personal Care T1019134 Bathing137 Lotion/Ointment138 Laundry139 Reading/Writing140 Supervision/Coaching/Cueing141 Incontinence Care145 Stairs201 In Person202 Via Telephone203 Other (Appointment Scheduling/Accompany Patient to medical appointment)204 Bath-Tub205 Bath-Shower206 Telephone/Communication207 Patient Requires Total Care209 Hair Care-Comb210 Grooming-Shave211 Caring for personal possessions212 Grooming-Nails213 Dressing215 Foot Care217 Toileting Commode218 Toileting-Bedpan/Urinal225 Assist with feeding229 Assist with walking231 Assist with home exercise program232 Range of motion exercises235 Take Temperature237 Take Blood Pressure244 Remind to take medication249 Light housekeeping251 Clean Patient Care Equipment252 Monitor Patient Safety
Employee Signature*
Employee Note: Your signature below affirms that the listed hours and services were carried out as per the consumer's POC.
Consumer Signature*
Consumer Note: Your signature below affirms that the listed hours and services were carried out per POC.
4807 Jonestown Rd #149, Harrisburg, PA 17109

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty: