PCA Care Plan Form

* Required Information

Agency Name *

Agency Phone Number *

Responsible Party Name

First Name *

Middle Initial

Last Name *

Address

Recipient Name

First Name

Last Name

MA Number

City

State

Zip

Date of Birth

Qualified Professional Name

First Name

Last Name

Shared Services

Yes

No

Number of Hours

Date Span

From

To

Activities of daily living (ADLs)

Check the applicable boxes below

ADL Notes

Instructions for PCA Help for Health Related Procedures and Tasks

Other living supports (IADLs)

IADLs Notes

EMERGENCY PROCEDURES / HOW TO USE 911

Examples of significant adverse conditions which may necessitate emergency contact and notifying 911 include:

Has trouble breathing or has stopped breathing;
Has no pulse;
Is bleeding severely;
Is in a state of deteriorating unconsciousness or is unconscious;
If a fracture is suspected;
If the person has been badly burned;
If unable to move one or more limbs;
Is having a seizure;
Has been poisoned;
Is having a diabetic emergency;
Has suffered a stroke; or
If there is any doubt as to seriousness of the situation

HOW TO USE 911

Dial 911;
State: “This is an emergency”;
Give the phone number you are calling from;
Give the address;
Describe the problem and how it happened,if known,otherwise just tell the facts and what has been observed;
Give your name;
Stay calm;
Reassure the client and family;
Follow direction of 911 dispatcher;and remember to;
Hang up last!

IF YOU DO NOT KNOW HOW TO GIVE CPR TELL THE DISPATCHER AT ONCE!

The regular PCA(s) shall be (Please enter Name and Phone Number)

Backup staffing required?

No (Informal supports used)

Yes (Complete information below)

Abuse Prevention Plan

What is this person's susceptibility to abuse by other persons including vulnerable adults?

Is this person at risk of abusing other vulnerable adults or self?

What measures shall be taken to minimize the risk of abuse to this person and others?

Additional Notes

January Anticipated Use (Choose One)

Regularly scheduled use of hours

Increased use of PCA hours

Decreased use of PCA hours

February Anticipated Use (Choose One)

Regularly scheduled use of hours

Increased use of PCA hours

Decreased use of PCA hours

March Anticipated Use (Choose One)

Regularly scheduled use of hours

Increased use of PCA hours

Decreased use of PCA hours

April Anticipated Use (Choose One)

Regularly scheduled use of hours

Increased use of PCA hours

Decreased use of PCA hours

May Anticipated Use (Choose One)

Regularly scheduled use of hours

Increased use of PCA hours

Decreased use of PCA hours

June Anticipated Use (Choose One)

Regularly scheduled use of hours

Increased use of PCA hours

Decreased use of PCA hours

July Anticipated Use (Choose One)

Regularly scheduled use of hours

Increased use of PCA hours

Decreased use of PCA hours

August Anticipated Use (Choose One)

Regularly scheduled use of hours

Increased use of PCA hours

Decreased use of PCA hours

September Anticipated Use (Choose One)

Regularly scheduled use of hours

Increased use of PCA hours

Decreased use of PCA hours

October Anticipated Use (Choose One)

Regularly scheduled use of hours

Increased use of PCA hours

Decreased use of PCA hours

November Anticipated Use (Choose One)

Regularly scheduled use of hours

Increased use of PCA hours

Decreased use of PCA hours

December Anticipated Use (Choose One)

Regularly scheduled use of hours

Increased use of PCA hours

Decreased use of PCA hours

Client or Responsible Party Name *

Date *

Qualified Professional Name *

Date *

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