PCA CHOICE PLAN
Consumer’s Name: PCA Name:
Plan Start Date: RN Supervisor:
Special Procedures / FrequencyO / Simple Dressing Change
O / Remind To Take Medications
O / Apply/Remove Ace Wraps
O / Apply/Remove Support Hose
O / Incentive Spirometer
O / Other (Describe Below)
/ Bathing / Frequency
O / Shower
O / Tub Bath
O / Partial Sponge Bath
O / Complete Sponge Bath
O / Shampoo Hair
O / Other (Describe Below)
Bowel Care / Frequency
O / Assist To/Empty Bedpan
O / Assist To/Empty Commode
O / Empty Ostomy Appliance
O / Perform Perneal Care
O / Tube Feeding
O / Other (Describe Below)
/ Skin Care / Frequency
O / Lotion (describe)
O / Massage (Describe)
O / Soak (Describe)
O / Trim Non-Diabetic Fingernails
O / Trim Non-Diabetic Toenails
O / Incontinence Skin Care
O / Other (Describe Below)
Bladder Care / Frequency
O / Empty Foley Catheter bag/urinal
O / Wash Skin Around Catheter
O / Perform Incontinence Care
O / Other (Describe Below)
/ Oral Hygene / Frequency
O / Brush Teeth
O / Clean Dentures
O / Brush Mouth w/toothettes
O / Other (describe Below)
Notes:
O / Select Clothes
O / Assist With Dressing
O / Brush/Comb Hair
O / Shave
O / Other (Describe Below)
/ Assist With Ambulation / Frequency
O / Walk W/Cane / O / W/Transfer Belt
O / Walk W/Walker / O / W/Transfer Belt
O / Walk W/Crutches / O / W/Transfer Belt
O / Does Not Get Out Of Bed/Chair
O / Other (Describe Below)
Perform Transfers / Frequency
O / Standby / O / W/Transfer Belt
O / Pivot Transfer / O / W/Transfer Belt
O / Sliding Board / O / W/Transfer Belt
O / Lift Transfer (1 Aide)
O / Lift Transfer (2 Aides)
O / Carried (Child <40lbs)
O / Other (Describe Below)
/ Exercises / Frequency
O / Passive Range Of Motion
O / Active Range Of Motion
O / Prescribed Exercises
O / Other (Describe Below)
Meal Preparation / Frequency
O / Prepare Meal
O / Serve Meal
O / Prepare Next Meal
O / Assist With Feeding
O / Encourage/Prepare Fluids
O / Other (Describe Below)
/ Housekeeping / Frequency
O / Clean Bathroom
O / Wash Dishes
O / Change Linens
O / Laundry
O / Empty Trash
O / Other (Describe Below)
Other Activities / Frequency
O
O
O
O
O
O
/ Notes:
Consumer Signature Staff Signature