Timesheet -Special Home Care
1250 N Mountain Rd Suite 309, Harrisburg PA 17112 Phone: 717-678-4714 Fax: 717-6453739 Email: info@specialhomecare.com EIN # 86-309947 AmeriHealth Caritas ID: 31101925 UPMC ID: 492590
Employee's Name
*
First Name
Last Name
Employee's Last 4 of Social Security Number
*
Patient's Name
*
First Name
Last Name
Address of Service
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Name
*
AmeriHealth Caritas
UPMC
Insurance ID Number
*
Date of Service
*
-
Month
-
Day
Year
Date
Start Time
*
Hour Minutes
AM
PM
AM/PM Option
End Time
*
Hour Minutes
AM
PM
AM/PM Option
Total Hours
*
What did you miss?
*
Clock-In
Clock-Out
Both Clock-In and Clock-Out
Clock-In or Clock-Out Early or Late
Other
Other
Reason
*
Forgot to either Clock-In or Clock-Out or Both
HHA or internet problem
Phone problem or technical issue
Consumer received service outside of home
Other
Other Reason
*
Duty Codes
*
100 Bath Tub
101 Bath Shower
102 Bath- Bed
103 Patient Requires Total Care
104 Mouth Care/Denture Care
105 Hair Care Comb
106 Hair Care Shampoo
107 Grooming Shave
108 Grooming Nails
109 Dressing
110 Skin Care
111 Foot Care
112 Toileting Diaper
113 Toileting Commode
114 Toileting- Bedpan/ Urinal
115 Toileting-Toilet
200 Patient is on a Prescribed diet
201 Prepare Breakfast
202 Prepare Lunch
203 Prepare Dinner
204 Prepare Snack
205 Assist with feeding
206 Record intake
207 Record Intake- Fluid
300 Transferring
301 Assist with walking
302 Patient walks with assistive device
303 assist with home exercise program
304 Range of Motion
305 Turning and positioning(at least Q2)
400 Take temperature
401 Take Pulse
402 Take Blood Pressure
403 Weight Patient
404 Take Respiration
409 remind to take Medication
500 Change Bed Linen
501 Patient Laundry
502 light Housekeeping
503 Clean Patient Care Equipment
504 Do Patient Shopping and Errands
505 Accompany Patient to Medical Appointment
506 Diversional Activities- Speak/Readf
507 Monitor Patient saftey
Employee Signature
*
Patient Signature
*
Note:
Your signatures affirm that the listed hours and services were carried out per POC.
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