Name: Medicaid Number: Week Of




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Facility Name:___________________________________________ – SERVICE LOG Personal Care Delivery
Name: Medicaid Number: Week Of:

Aides RN:


MEAL PREP





B

L

B

L

B

L

B

L

B

L

B

L

B

L

S

B

S

B

S

B

S

B

S

B

S

B

S

B







BATHING






















PERSONAL HYGIENE






















DRESSING






















BLADDER/BOWEL

REQUIREMENTS
























MOBILITY &

AMBULATION
























LAUNDRY






















INCIDENTAL HOUSEKEEPING






















SHOPPING FOR PERSONAL MAINT. ITEMS























* To the extent permitted by the Arkansas Nurse Practice Act and implementing regulations.

RN Directions:

ASSISTANCE WITH EATING





B

L

B

L

B

L

B

L

B

L

B

L

B

L

S

B

S

B

S

B

S

B

S

B

S

B

S

B







ITEM

SUN

MON

TUES

WED

THUR

FRI

SAT

ASSISTANCE WITH MEDICATIONS*





M

N

M

N

M

N

M

N

M

N

M

N

M

N

S

B

S

B

S

B

S

B

S

B

S

B

S

B







DMS-873 (10-12)

Page 1 of 3




AIDES NOTES: Resident Name:

Week Of:
Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Note: Aide Notes are to be recorded daily and initialed by the primary aide responsible for the recipient’s care on that day.  The notes should contain a statement of the recipient’s current condition and any observations regarding changes from the normal observed condition.  Aide Notes should also include any difficulties or situations that caused a change in services that were to be completed on that date. 

Certification Statement:

Personal care services are individually designed to assist with a client’s physical dependency needs related to prescribed routines and activities of daily living. The individualized service plan is designed to correlate with the physical dependency needs identified in the client’s assessment. Services must be provided in accordance with the client’s individualized service plan and service delivery must be documented on the checklist detailed above.
The provider of personal care services certifies through submission of a claim for personal care services that services have been provided in accordance with the Arkansas Medicaid Personal Care Program Manual, and with the prescribed service plan and properly documented through the completion of the Service Log and Aides Notes. Service delivery (number of units delivered) must be substantiated through the provider’s payroll records. Providers will only be required to provide payroll records when requested by DHS.
DMS-873 (10-12)

Page 2 of 3



Arkansas Department of Human Services

Division of Medical Services

Instructions for completing the Service Log & Aide Notes

For Personal Care Services in a Residential Care Facility or Assisted Living Facility

1. Record Facility Name.


2. Complete resident specific information:

    • Resident Name

    • Medicaid Number

    • Indicate week for which Service Log applies. (7 day period)

3. Aides: All aides providing personal care service for this resident must be identified on the service log. The RN providing supervisory review must also be identified.


4. The aide must indicate by day each time the service plan required service is completed for the following service plan items: (Aide must indicate service delivery by initialing in the appropriate box. Aide may sign as many as four times per day. Bedtime is any period of time between supper and actual placement in bed.)

Assistance with Medications:

Identified as: M=Morning, N=Noon, S=Supper, B=Bedtime

Meal Preparation:

Identified as: B=Breakfast, L=Lunch, S=Supper, B=Bedtime

Assistance with Eating:

Identified as: B=Breakfast, L=Lunch, S=Supper, B=Bedtime
5. The aide must indicate by day that this service plan required service has been completed. (Aide must indicate service delivery by initialing in the appropriate box. Only requires a single entry per day)

Bathing


Personal Hygiene

Dressing


Bladder/Bowel Requirements

Mobility & Ambulation



Laundry

Incidental Housekeeping



Shopping for Personal Maintenance Items
6. RN Directions: RN should note any special conditions of the recipient or instructions to the aide.
7. Aides Notes: Aide Notes are to be recorded daily and initialed by the primary aide responsible for the recipient’s care on that day.  The notes should contain a statement of the recipient’s current condition and any observations regarding changes from the normal observed condition.  Aide Notes should also include any difficulties or situations that caused a change in services that were to be completed on that date. 
RECORD RETENTION:
All records must be kept for a period of five years from the ending date of service or until all audit questions, appeal hearings, investigations or court cases are resolved, whichever period is longer.
DMS-873 (10-12)

Page 3 of 3


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