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					                                              Alliance Health Care - 2260 Cliff Road - Eagan, MN 55122             Phone: 651-895-8030       Fax: 651-895-8070

                                                                                PCA CHOICE - AHS
Client Name:_____________________________________Employee Name________________________________________File #_________________

                                      For the week of: Sunday_____________________thru Saturday_______________________

         Sunday                        Monday                        Tuesday                      Wednesday                     Thursday                         Friday                     Saturday
Date:                         Date:                         Date:                         Date:                         Date:                         Date:                         Date:

Time In:                      Time In:                      Time In:                      Time In:                      Time In:                      Time In:                      Time In:

Time Out:                     Time Out:                     Time Out:                     Time Out:                     Time Out:                     Time Out:                     Time Out:

Please check all that apply   Please check all that apply   Please check all that apply   Please check all that apply   Please check all that apply   Please check all that apply   Please check all that apply
for this day:                 for this day:                 for this day:                 for this day:                 for this day:                 for this day:                 for this day:

_____Bowel/ Bladder           _____Bowel/ Bladder           _____Bowel/ Bladder           _____Bowel/ Bladder           _____Bowel/ Bladder           _____Bowel/ Bladder           _____Bowel/ Bladder
_____Skin Care                _____Skin Care                _____Skin Care                _____Skin Care                _____Skin Care                _____Skin Care                _____Skin Care
_____Range of Motion          _____Range of Motion          _____Range of Motion          _____Range of Motion          _____Range of Motion          _____Range of Motion          _____Range of Motion
_____Respiratory              _____Respiratory              _____Respiratory              _____Respiratory              _____Respiratory              _____Respiratory              _____Respiratory
     Assistance                    Assistance                    Assistance                    Assistance                    Assistance                    Assistance                    Assistance
_____Transfers/Mobility       _____Transfers/Mobility       _____Transfers/Mobility       _____Transfers/Mobility       _____Transfers/Mobility       _____Transfers/Mobility       _____Transfers/Mobility
_____Bathing, Grooming,       _____Bathing, Grooming,       _____Bathing, Grooming,       _____Bathing, Grooming,       _____Bathing, Grooming,       _____Bathing, Grooming,       _____Bathing, Grooming,
     Hair Washing                  Hair Washing                  Hair Washing                  Hair Washing                  Hair Washing                  Hair Washing                  Hair Washing
_____Turning/Positioning      _____Turning/Positioning      _____Turning/Positioning      _____Turning/Positioning      _____Turning/Positioning      _____Turning/Positioning      _____Turning/Positioning
_____Medication               _____Medication               _____Medication               _____Medication               _____Medication               _____Medication               _____Medication
     Assistance                    Assistance                    Assistance                    Assistance                    Assistance                    Assistance                    Assistance
_____Orthotics                _____Orthotics                _____Orthotics                _____Orthotics                _____Orthotics                _____Orthotics                _____Orthotics
     Maintenance                   Maintenance                   Maintenance                   Maintenance                   Maintenance                   Maintenance                   Maintenance
_____Cleaning Medical         _____Cleaning Medical         _____Cleaning Medical         _____Cleaning Medical         _____Cleaning Medical         _____Cleaning Medical         _____Cleaning Medical
     Equipment                     Equipment                     Equipment                     Equipment                     Equipment                     Equipment                     Equipment
_____Dressing/                _____Dressing/                _____Dressing/                _____Dressing/                _____Dressing/                _____Dressing/                _____Dressing/
     Undressing                    Undressing                    Undressing                    Undressing                    Undressing                    Undressing                    Undressing
_____Assistance               _____Assistance               _____Assistance               _____Assistance               _____Assistance               _____Assistance               _____Assistance
     with Food                     with Food                     with Food                     with Food                     with Food                     with Food                     with Food
_____Accompany Client         _____Accompany Client         _____Accompany Client         _____Accompany Client         _____Accompany Client         _____Accompany Client         _____Accompany Client
     to Medical Appt               to Medical Appt               to Medical Appt               to Medical Appt               to Medical Appt               to Medical Appt               to Medical Appt
_____Daily Liviing Skills     _____Daily Liviing Skills     _____Daily Liviing Skills     _____Daily Liviing Skills     _____Daily Liviing Skills     _____Daily Liviing Skills     _____Daily Liviing Skills
_____Redirect Behaviors       _____Redirect Behaviors       _____Redirect Behaviors       _____Redirect Behaviors       _____Redirect Behaviors       _____Redirect Behaviors       _____Redirect Behaviors

Total Hours:                  Total Hours:                  Total Hours:                  Total Hours:                  Total Hours:                  Total Hours:                  Total Hours:


EMPLOYEE SIGNATURE:                                                                                                                                              Total Hours For the Week:

CLIENT/RESPONSIBLE PARTY SIGNATURE (Please authorize all hours before signing here):


                                         NOTE: ALL TIMESHEETS MUST BE RECEIVED EVERY MONDAY BY 10:00 AM FOLLOWING THE WEEK WORKED

				
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posted:12/28/2011
language:English
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