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OASIS SOC ROC INCLUDING COMPREHENSIVE ADULT NURSING ASSESSMENTWITH CMS 485 (POC) INFORMATION
DATE
REASON FOR ASSESSMENT Resumption of CareStart of CareTIME OUTTIME IN
(M0010) CMS Certification Number (Provider)
(M0030) Start of Care Date
(M0032) Resumption of Care DateNA - Not Applicable
(M0016) Branch ID Number
(M0018) National Provider Identifier (NPI) for the attending physicianwho has signed the plan of care
Unknown or Not Available----------
EmergencyDisaster Plan Classification Code
(M0150) Current Payment Sources for Home Care (Mark all that apply)(M0140) RaceEthnicity (Mark all that apply)0 - None no charge for current services1 - American Indian or Alaska Native1 - Medicare (traditional fee-for-service)2 - Asian2 - Medicare (HMOmanaged careAdvantage plan)3 - Black or African-American3 - Medicaid (traditional fee-for-service)4 - Hispanic or Latino4 - Medicaid (HMOmanaged care)5 - Native Hawaiian or Pacific Islander5 - Workers compensation6 - White6 - Title programs (eg Title 111 V or XX)7 - Other government (eg TriCare VA etc)
8 - Private insurance9 - Private HMOmanaged care
10 - Self-pay
11 - Other (specify)UK - Unknown
PATIENT NAME - Last First Middle Initial Med Record
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Page 1 of 20
(M0014) Branch Identification Branch State
5
yearmonth day
month day
year
Agency Name________________________________________
NA - Not Applicable
Employees NameTitle Completing the OASIS_____________________________________________________________
According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless it displays a valid OMB control number The valid OMB control number for this information collection instrument is 0938-0760 The time required to complete this information collection is estimated to average 07 minutes per response including the time to review instructions search existing data resources gather the data needed and complete and review the information collection If you have comments concerning this form please write to CMS 7500 Security Boulevard Attn PRA Reports Clearance Officer Baltimore Maryland 21244-1850
Physician name _______________________________
Address ___________________________ _________________________________________Phone Number ______________________________
24
Other Physician (if any) _______________________________
Address ___________________________ _________________________________________Phone Number ______________________________
(M0020) Patient ID Number __ __ __ __ __ __ __ __ __ __ __ __ __ __ (Medical Record)
4
2
(M0040) Patient Name
______________________ ____ _________________________ _______(First) (M I) (Last) (Suffix)Address _____________________________________________________ _____________________________________________________Patient Phone __________________________
(M0050) Patient State of Residence __ __
(M0060) Patient Zip Code _ _ _ _ _ _ _ _ _
(M0063) Medicare Number __ __ __ __ __ __ __ __ __ __ __ __ (including suffix) NA No Medicare
(M0064) Social Security Number __ __ __ - __ __ - __ __ __ __ Unknown or Not Available
(M0065) Medicaid Number __ __ __ __ __ __ __ __ __ __ __ __ __ __ NA No Medicaid(M0066) Birth Date __ __ __ __ __ __ __ __ month day year
(M0069) Gender 1 - Male 2 - Female
6
Certification Period
From _____ To 3
1
18
9
EMERGENCY CONTACTAddressPhone RelationshipOTHER
6
REFERRAL SOURCE (if not from Primary Physician)
Phone
Evacuation Form needed Emergency Registration Completed (please document)
Fax
PHYSICIAN Date last contacted Date last visited
Reason
Phone
7
ALF AFHC (circle)
Name
Phone
It is the policy of our Agency that home health services shall be available and shall be rendered to the total population of our area of services regardless of the recipients race sexual orientation religion age sex disabilities ethniccultural background or national origin
Comment
Non-Discrimination statement
PT ID PERFORMED VIA NAME DOB FACE RECOGNITION AND ADDRESS BEFORE SERVICE PROVIDED
Quality Assurance IndicatorQA
POC (CMS - 485) BoxSG Safety Goal
SG
Advance DirectiveDNR Information completed on Admission Forms YesN oComments
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Patient Name Med Record CLINICAL RECORD ITEMS
(M0104) Date of Referral Indicate the date that the written or verbalreferral for initiation or resumption of care was received by the HHA
(M0080) Discipline of Person Completing Assessment1-RN 3-SLPST2-PT 4-OT
year(M0090) Date Assessment Completed month day
month day year(M0110) Episode Timing Is the Medicare home health payment episodefor which this assessment will define a case mix group an earlyepisode or a later episode in the patients current sequence ofadjacent Medicare home health payment episodes
(M0100) This Assessment is Currently Being Completed for theFollowing Reason StartResumption of Care
1 - Start of care-further visits plannedNA - Not Applicable No Medicare1 - Early3 - Resumption of care (after inpatient stay) case mix group to be defined
by this assessment2 - Later(complete M0032)
UK - Unknown[M0102) Date of Physician-ordered Start of Care (Resumption ofCare) If the physician indicated a specific start of care (resumption ofcare) date when the patient was referred for home health servicesrecord the date specified
bull Early Episode is first or second episode in a sequence of adjacent episodesbull Later is the third episode and beyond in sequence of adjacent episodes(Adjacent episodes are separated by 60 days or fewer between episodes)Case mix adjustment -- Adjusting payment for a beneficiarys condition and needsOASIS items describing the patients condition as well as the expected therapy needs are used to determine the case-mix adjustment to the payment rate This adjustment is the case-mix adj Eighty case-mix groups or Home Health Resource Groups (HHRG) are available for classification
(Go to M0110 if date entered)
NA - No specific SOC date ordered by physician
PATIENT HISTORY AND DIAGNOSES(M1000) From which of the following Inpatient Facilities was the (M1016) Diagnoses Requiring Medical or Treatment Regimen Change Within Past 14 Days
List the patients Medical Diagnoses and ICD-9-C M codes at the level ofpatient discharged during the past 14 days (Mark all that apply)highest specificity for those conditions requiring changed medical or1 - Long-term nursing facility (NF)treatment regimen within the past 14 days (no surgical E-codes or V-codes)
2 - Skilled nursing facility (SNFTCU)ICD-9-C M Code3 -Short-stay acute hospital (IPP S) Changed Medical Regimen Diagnosis
4 - Long-term care hospital (LTCH)a )
5 - Inpatient rehabilitation hospital or unit (IRF)b )(6 - Psychiatric hospital or unit
7 - Other (specify) )(NA - Patient was not discharged from an inpatient facility
d )((Go to M1016)
e )((M1005) Inpatient Discharge Date (most recent) UK - Unknown )(
month day yearNA - Not applicable (no medical or treatment regimen changes within
(M1010) List each Inpatient Diagnosis and ICD-9-C M code at the level the past 14 days)of highest specificity for only those conditions treated during aninpatient stay within the last 14 days (no E-codes or V-codes) (MI1018) Conditions Prior to Medical or Treatment Regimen Change
or Inpatient Stay Within Past 14 Days If this patient experienced aninpatient facility discharge or change in medical or treatment regimenwithin the past 14 days indicate any conditions which existed prior tothe inpatient stay or change in medical or treatment regimen
(Mark all that apply)
ICD-9-CM CodeInpatient Facility Diagnosis
a )
b ( )1 - Urinary incontinence
( )C 2 - Indwellingsuprapubic catheter3 - Intractable paind ( )4 - Impaired decision-making
e ( ) 5 - Disruptive or socially inappropriate behaviorf 6 - Memory loss to the extent that supervision required( )
7 - None of the above(M1012) List each Inpatient Procedure and the associated ICD-9-CMprocedure code relevant to the plan of care
NA - No inpatient facility discharge and no change in medical ortreatment regimen in past 14 days
Inpatient Procedure Procedure Code UK - Unknown
a ( )
b ( )
( )C
d ( )NA - Not applicableUK - Unknown
Page 2 of 20
month day year
(
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(
c
f
Comment (if needed)
5-Excellent3-Fair 4 Good1- Poor 2- Guarded
PROGNOSIS 20
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PATIENT HISTORY AND DIAGNOSES (Contd)(M1020M1022M1024) Diagnoses Symptom Control and Payment Diagnoses List each diagnosis for which the patient is receiving home care(Column 1) and enter its ICD-9-CM code at the level of highest specificity (no surgicalprocedure codes) (Column 2) Diagnoses are listed in the orderthat best reflect the seriousness of each condition and support the disciplines and services provided Rate the degree of symptom control for eachcondition (Column 2) Choose one value that represents the degree of symptom control appropriate for each diagnosis V-codes (for M1020 or M1022)or E-codes (for M1022 only) may be used ICD-9-CM sequencing requirements must be followed if multiple coding is indicated for any diagnoses If aV-code is reported in place of a case mix diagnosis then optional item M1024 Payment Diagnoses (Columns 3 and 4) may be completed A case mixdiagnosis is a diagnosis that determines the Medicare PPS case mix group Do not assign symptom control ratings for V- or E-codesCode each row according to the following directions for each column
Column 1 Enter the description of the diagnosisColumn 2 Enter the ICD-9-CM code for the diagnosis described in Column 1
Rate the degree of symptom control for the condition listed in Column 1 using the following scale0 - Asymptomatic no treatment needed at this time1 - Symptoms well controlled with current therapy2 - Symptoms controlled with difficulty affecting daily functioning patient needs ongoing monitoring3 - Symptoms poorly controlled patient needs frequent adjustment in treatment and dose monitoring4 - Symptoms poorly controlled history of re-hospitalizations
Note that in Column 2 the rating for symptom control of each diagnosis should be used to determine the sequencing of the diagnoseslisted in Column 1 These are separate items and sequencing may not coincide Sequencing of diagnoses should reflect the seriousnessof each condition and support the disciplines and services provided
Column 3 (OPTIONAL) If a V-code is assigned to any row in Column 2 in place of a case mix diagnosis it may be necessary to complete optionalitem M1024 Payment Diagnoses (Columns 3 and 4) See OASIS-C Guidance Manual
guidelines enter the diagnosis descriptions and the ICD-9-C M codes in the same row in Columns 3 and 4 For exampleif the case mix diagnosis is a manifestation code record the diagnosis description and ICD-9-C M code for the underlying condition in Column 3 of that rowand the diagnosis description and ICD-9-CM code for the manifestation in Column 4 of that row Otherwise leave Column 4 blank in that row
(M1024) Payment Diagnoses (OPTIONAL)(M1020) Primary Diagnosis amp (M1022) Other DiagnosesCOLUMN 1 COLUMN 2 COLUMN 4
ICD-9-CM and symptom controlrating for each condition Notethat the sequencing of these
ratings may not match thesequencing of the diagnoses
Complete only if the V-code inColumn 2 is reported in place of a casemix diagnosis that is a multiple codingsituation (eg a manifestation code)
Diagnoses (Sequencing of diagnoses should reflect the seriousness of each condition andsupport the disciplines and services provided)
Description ICD-9-CM
(M1020) Primary Diagnosis
a
(V- or E-codes NOT allowed)
a
(V- or E-codes NOT allowed)
a
)(
b
(V- or E-codes are allowed) (V- or E-codes NOT allowed)
b
( )
(V- or E-codes NOT allowed)
b
)( c
Date OE
C
( )
C
)(
d
Date OE
d ( )
4210 3
d
( )
d
e
Date OE
e ( )
421 30
e
( )
e
)( f
Date OE
f f
ICD-9-CM Surgical Procedure
Date )(
Date )(
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Patient Name Med Record
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Column 4 (OPTIONAL) If a V-code in Column 2 is reported in place of a case mix diagnosis that requires multiple diagnosis codes under ICD-9-C M coding
COLUMN 3
Complete if a V-code is assignedunder certain circumstances to
Column 2 in place of acase mix diagnosis
DescriptionICD-9-CM
Symptom Control Rating Description ICD-9-CM
11
Date OE
Date OE
(M1022) Other Diagnoses 13
1212
( )
( )
f ( )
1 2 40 3
a ( )
1 2 40 3
b ( )
1 2 40 3
c ( )
1 2 40 3
(V-codes are allowed)
)(
)(
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PATIENT HISTORY AND DIAGNOSES (Contd)MAIN REASON FOR HOME HEALTH CARE
HOMEBOUND REASON
Needs assistance for all activities (ADLs)
Requires assistance to ambulateDecreased Range of MotionGeneralized Weakness
Confusion unable to go out of home alone
Severe SOB SOB upon exertion amb ____ feet
Unable to safely leave home without assistance
Medical restrictions
Dependent upon adaptive device(s)
PREVIOUS HISTORY ANDOR PREVIOUS OUTCOMES (Reference M1000 M1005 M1010 and M1012)
Cardiac
Diabetes
HypertensionRespiratory
Cancer (site
Fractures (siteOsteoporosisOsteoarthritis
)
Infection
Immunosuppressed
Open Wound (site
Surgeries (site
Other (specify)
IMMUNIZATIONS Check if current within last 12 months H1N1Influenzaflu regular seasonalOtherFollowing immunization guidelines Pneumonia Tetanus
Pending or NeededPRIOR HOSPITALIZATIONS (in the last six months) No Yes Number of timesReason (s) Date(s)
(M1030) Therapies the patient receives at home (Mark all that apply) 1 - Intravenous or infusion therapy (excludes TPN) 2 - Parenteral nutrition (TPN or lipids) 3 - Enteral nutrition (nasogastric gastrostomy jejunostomy or any
other artificial entry into the alimentary canal) 4 - None of the above
(M1032) Risk for Hospitalization Which of the following signs orsymptoms characterize this patient as at risk for hospitalization
(Mark all that apply)1 - Recent decline in mental emotional or behavioral status2 - Multiple hospitalizations (2 or more) in the past 12 months
113 - History of falls (2 or more falls - or any fall with an injury - in thepast year)
4 -Taking five or more medications(M1036) Risk Factors either present or past likely to affect current
health status andor outcome (Mark all that apply)5 - Frailty indicators eg weight loss self-reported exhaustion6 - Other
1 - Smoking7 - None of the above2 - Obesity(M1034) Overall Status Which description best fits3 - Alcohol dependencythe patientrsquos overall status (Check one)4 - Drug dependency0 -The patient is stable with no heightened risk(s) for serious
complications and death (beyond those typical of the 5 - None of the abovepatientrsquos age) 6 - UK- Unknown
1 - The patient is temporarily facing high health risk(s) but is likely toreturn to being stable without heightened risk(s) for serious complicationsand death (beyond those typical of the patientrsquos age)
Comments (if needed)
2 - The patient is likely to remain in fragile health and have ongoinghigh risk(s) of serious complications and death
3 - The patient has serious progressive conditions that could leadto death within a year
UK - The patients situation is unknown or unclear
LIVING ARRANGEMENTS(M1100) Patient Living Situation Which of the following best describes the patients residential circumstance and availability of assistance
(Check one box only)
Availability of Assistance
Occasional No AssistanceAround the Clock Regular Daytime Regular NighttimeLiving Arrangement AvailableShort-term Assistance
a Patient lives alone 01 02 03 04 05b Patient lives with other
person(s) in the home 06 07 08 09 10
c Patient lives in congregatesituation (eg assisted living) 1 1 12 13 14 15
Patient Name Med Record
Page 4 of 20
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(Mark all that apply)
Other (specify)
Needs assist of 1-2 persons
Bedbound (PartialComplete)
MobilityAmbulatory device(s) used
Unsteady Gait18A
) )
Decubitus (site
Insulin DependentNon Insulin Dependent
))
Gastrointestinal Genitourinary
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LIVING ARRANGEMENTS (Contd) SENSORY STATUS HEARING
Yes N o
MOUTH
Other family member(CG) available to help patient with care safely administration of injection procedures
(M1210) Ability to Hear (with hearing aid or hearing appliance if normallyused)
0 - Adequate hears normal conversation without difficulty
Other agencies involved in care
1- Mildly to Moderately Impaired difficulty hearing in someenvironments or speaker may need to increase volume or speakdistinctly
2- Severely Impaired absence of useful hearing
SENSORY STATUS VISION
UK - Unable to assess hearing
(M1200) Vision (with corrective lenses if the patient usually wears them)
No Problem
0 - Normal vision sees adequately in most situations can seemedication labels newsprint
R LHearing aidDeaf R LHOH R LVertigo Tinnitus R L
1 - Partially impaired cannot see medication labels or newsprint buton see obstacles in path and the surrounding layout can countfingers at arms length
(specify)Other
2 - Severely impaired cannot locate objects without hearing or touchingthem or patient nonresponsive
Glasses Glaucoma JaundiceContacts R L Blurred vision
Ptosis
SPEECH and ORAL (VERBAL) CONTENTEXPRESSION
Prosthesis R L OtherLegally Blind RL
(M1220) Understanding of Verbal Content in patients own language(with hearing aid or device if used)
InfectionsCataract surgery Site
0 - Understands clear comprehension without cues or repetitions
Date
1- Usually Understands understands most conversations butmisses some partintent of message Requires cues at times tounderstand
Is there any function safety impact in the patient due to impaired vision(explain)
2 - Sometimes Understands understands only basic conversationsor simple direct phrases Frequently requires cues tounderstand
3 - RarelyNever UnderstandsUK - Unable to assess understanding
NOSE
(M1230) Speech and Oral (Verbal) Expression of Language(in patients own language)
No Problem
0 - Expresses complex ideas feelings and needs clearly completely
Congestion Loss of smellEpistaxis Sinus problem
and easily in all situations with no observable impairment
Other (specify)
1 - Minimal difficulty in expressing ideas and needs (may take extratime makes occasional errors in word choice grammar or speechintelligibility needs minimal prompting or assistance)
2 - Expresses simple ideas or needs with moderate difficulty (needsprompting or assistance errors in word choice organization orspeech intelligibility) Speaks in phrases or short sentences
THROAT
3 - Has severe difficulty expressing basic ideas or needs and requires
No Problem
maximal assistance or guessing by listener Speech limited tosingle words or short phrases
Dysphagia HoarsenessLesions explain
Sore throat
Other (specify)
4 - Unable to express basic needs even with maximal prompting orassistance but is not comatose or unresponsive (eg speech isnonsensical or unintelligible)
5 - Patient nonresponsive or unable to speak
Page 5 of 20
Patient Name Med Record
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Primary Caregiver (CG) Significant otherName
Phone number if different from patient
Relationshiphealth statusability to help
Make medical care decisions for the patient
Specify
No Problem
Other eyes surgery SiteDate
Cataract R L
Any nose surgeryDate
Any ears surgeryprocedureDate
Dentures (mark) Upper Lower Partial
MassesTumors site ________________________
Gingivitis Ulcerations Toothache
No Problem
Other (specify)
Any surgeryprocedureDate
Any paid help explain
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PAIN
Occasionally ContinuousIntermittent
Intensity (using scales below)Wong-Baker FACES Pain Rating Scale
Movement Ambulation ImmobilityWhat makes pain worse
Other
Is there a regular pattern to the pain (explain)
Change positionHeat IceunguentWhat relief pain
EntertainmentMedicationRestRelaxation
NO HURT HURTS HURTS HURTS HURTS HURTSLITTLE BIT LITTLE MORE EVEN MORE WHOLE LOT WORSE
Other
2
NeverIf taken medication how often is needed
0 4 6 8 10
N o Moderate Worst
More than 3 timesdayLess than daily
2-3 timesday
Pain Pain Possible Pain
Occasionally Continuously IntermittentDoes the pain radiate
NoYesCurrent pain control medications adequateComment
Yes N o
0-10 Scale (patient reporting)
Implications Care Plan
FACES Scale (Observed)Collected using
StaffPatientHas the physician been notified by theWhat was the outcome
ENDOCRINE STATUS
No Problem
Diabetes Type I Juvenile Type II OnsetExacerbation dateDietOral control (specify)INSULIN dosage frequency scale explain
Self NurseCaregiverFamilyAdministered byOther
Any symptoms present (circle)
Mark Todays visit PatientCaregiver reported
Lab slip
A1c _______ mgdL DateTimeBS
Pain Assessment site 1 site 3
Location site
New Onset Exacerbation
Present level (0-10)
Pain type (aching burningradiating neuralgia etc)Feeling of pain internal external acute chronic
Before meal Postprandial Random HSFBSPatientCaregiver ReportBlood sugar ranges
Monitored byFrequency
Able to use Glucometer
Diabetes Management Problems (explain)
Intolerance to heatcold
Fatigue
Enlarged thyroid (hyperhypothyroid)Other Endocrine problems
(M1240) Has this patient had a formal Pain Assessment using astandardized pain assessment tool (appropriate to the patients ability tocommunicate the severity of pain)
Anemia (specify type if known)
Bleeding problems GI GU GYN unknown Hemophilia
Other
0 - No standardized assessment conducted1 - Yes and it does not indicate severe pain
SKIN INTEGUMENTARY STATUS
2 - Yes and it indicates severe pain
No Problem
(M1242) Frequency of Pain Interfering with patients activity or
Mark all applicable skin conditions listed below
movement
Turgor Good Poor
0 - Patient has no pain
Itch Rash Dry Scaling RednessBruises Ecchymosis Pallor Jaundice
1 - Patient has pain that does not interfere with activity or movement2 - Less often than daily
Other (specify)
3 - Daily but not constantly4 -All of the time
Page 6 of 20
How does the pain interfere with their functionalactivity level ADLs(explain)
QA
site 2
Patient Name Med Record
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No Problem
Best Pain Scale 0-10
Worst Pain Scale 0-10
Frequency
NoYesPatient complains about pain
Pain is worse morning afternoon evening nights
NON-VERBAL INDICATORS Afraid to moveCryingGuarding MoaningOther
SleepTime at Bed Minimal activityTransfer
MassageTherapy Walk Go to bed
Daily
Yes N o
Since
Hyperglycemia Polyuria Glycosuria PolydipsiaHypoglycemia Sweats Weak Faint Stupor Polyphagia
Self CaregiverFamily OtherNurse
HEMATOLOGY IMMUNOLOGIC STATUS
Immunodeficiency problems (explain)
No Problem
From Hockenberry MJ Wilson D Winkelstein ML Wongs Essentials of Pediatric Nursing ed 7 St Louis 2005 p 1259 Used with permission Copyright Mosby
Explain to the person that each face is for a person who feels happy because he has no pain (hurt) or sad because he has some or a lot of pain Face 0 is very happy because he doesnt hurt at all Face 1 hurts just a little bit Face 2 hurts a little more Face 3 hurts even more Face 4 hurts a whole lot Face 5 hurts as much as you can imagine although you don t have to be crying to feel this bad Ask the person to choose which face that best describes how he is feeling
Frequently
Does one medication relieve pain better than another If yes which one
Pain control treatmentmeds Side effect (mark) Nausea
Confusion OtherSleepy Vomiting
Frequently
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Patient Name Med Record CLINICAL RECORD ITEMS
(M0104) Date of Referral Indicate the date that the written or verbalreferral for initiation or resumption of care was received by the HHA
(M0080) Discipline of Person Completing Assessment1-RN 3-SLPST2-PT 4-OT
year(M0090) Date Assessment Completed month day
month day year(M0110) Episode Timing Is the Medicare home health payment episodefor which this assessment will define a case mix group an earlyepisode or a later episode in the patients current sequence ofadjacent Medicare home health payment episodes
(M0100) This Assessment is Currently Being Completed for theFollowing Reason StartResumption of Care
1 - Start of care-further visits plannedNA - Not Applicable No Medicare1 - Early3 - Resumption of care (after inpatient stay) case mix group to be defined
by this assessment2 - Later(complete M0032)
UK - Unknown[M0102) Date of Physician-ordered Start of Care (Resumption ofCare) If the physician indicated a specific start of care (resumption ofcare) date when the patient was referred for home health servicesrecord the date specified
bull Early Episode is first or second episode in a sequence of adjacent episodesbull Later is the third episode and beyond in sequence of adjacent episodes(Adjacent episodes are separated by 60 days or fewer between episodes)Case mix adjustment -- Adjusting payment for a beneficiarys condition and needsOASIS items describing the patients condition as well as the expected therapy needs are used to determine the case-mix adjustment to the payment rate This adjustment is the case-mix adj Eighty case-mix groups or Home Health Resource Groups (HHRG) are available for classification
(Go to M0110 if date entered)
NA - No specific SOC date ordered by physician
PATIENT HISTORY AND DIAGNOSES(M1000) From which of the following Inpatient Facilities was the (M1016) Diagnoses Requiring Medical or Treatment Regimen Change Within Past 14 Days
List the patients Medical Diagnoses and ICD-9-C M codes at the level ofpatient discharged during the past 14 days (Mark all that apply)highest specificity for those conditions requiring changed medical or1 - Long-term nursing facility (NF)treatment regimen within the past 14 days (no surgical E-codes or V-codes)
2 - Skilled nursing facility (SNFTCU)ICD-9-C M Code3 -Short-stay acute hospital (IPP S) Changed Medical Regimen Diagnosis
4 - Long-term care hospital (LTCH)a )
5 - Inpatient rehabilitation hospital or unit (IRF)b )(6 - Psychiatric hospital or unit
7 - Other (specify) )(NA - Patient was not discharged from an inpatient facility
d )((Go to M1016)
e )((M1005) Inpatient Discharge Date (most recent) UK - Unknown )(
month day yearNA - Not applicable (no medical or treatment regimen changes within
(M1010) List each Inpatient Diagnosis and ICD-9-C M code at the level the past 14 days)of highest specificity for only those conditions treated during aninpatient stay within the last 14 days (no E-codes or V-codes) (MI1018) Conditions Prior to Medical or Treatment Regimen Change
or Inpatient Stay Within Past 14 Days If this patient experienced aninpatient facility discharge or change in medical or treatment regimenwithin the past 14 days indicate any conditions which existed prior tothe inpatient stay or change in medical or treatment regimen
(Mark all that apply)
ICD-9-CM CodeInpatient Facility Diagnosis
a )
b ( )1 - Urinary incontinence
( )C 2 - Indwellingsuprapubic catheter3 - Intractable paind ( )4 - Impaired decision-making
e ( ) 5 - Disruptive or socially inappropriate behaviorf 6 - Memory loss to the extent that supervision required( )
7 - None of the above(M1012) List each Inpatient Procedure and the associated ICD-9-CMprocedure code relevant to the plan of care
NA - No inpatient facility discharge and no change in medical ortreatment regimen in past 14 days
Inpatient Procedure Procedure Code UK - Unknown
a ( )
b ( )
( )C
d ( )NA - Not applicableUK - Unknown
Page 2 of 20
month day year
(
wwwpnsystemcom 3058185940 The Outcome and Assessment Information Set (OASIS) is the intellectual property of the Center for Health Services and Policy Research Denver Colorado It is used with permission Expiration date 7312012
(
c
f
Comment (if needed)
5-Excellent3-Fair 4 Good1- Poor 2- Guarded
PROGNOSIS 20
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PATIENT HISTORY AND DIAGNOSES (Contd)(M1020M1022M1024) Diagnoses Symptom Control and Payment Diagnoses List each diagnosis for which the patient is receiving home care(Column 1) and enter its ICD-9-CM code at the level of highest specificity (no surgicalprocedure codes) (Column 2) Diagnoses are listed in the orderthat best reflect the seriousness of each condition and support the disciplines and services provided Rate the degree of symptom control for eachcondition (Column 2) Choose one value that represents the degree of symptom control appropriate for each diagnosis V-codes (for M1020 or M1022)or E-codes (for M1022 only) may be used ICD-9-CM sequencing requirements must be followed if multiple coding is indicated for any diagnoses If aV-code is reported in place of a case mix diagnosis then optional item M1024 Payment Diagnoses (Columns 3 and 4) may be completed A case mixdiagnosis is a diagnosis that determines the Medicare PPS case mix group Do not assign symptom control ratings for V- or E-codesCode each row according to the following directions for each column
Column 1 Enter the description of the diagnosisColumn 2 Enter the ICD-9-CM code for the diagnosis described in Column 1
Rate the degree of symptom control for the condition listed in Column 1 using the following scale0 - Asymptomatic no treatment needed at this time1 - Symptoms well controlled with current therapy2 - Symptoms controlled with difficulty affecting daily functioning patient needs ongoing monitoring3 - Symptoms poorly controlled patient needs frequent adjustment in treatment and dose monitoring4 - Symptoms poorly controlled history of re-hospitalizations
Note that in Column 2 the rating for symptom control of each diagnosis should be used to determine the sequencing of the diagnoseslisted in Column 1 These are separate items and sequencing may not coincide Sequencing of diagnoses should reflect the seriousnessof each condition and support the disciplines and services provided
Column 3 (OPTIONAL) If a V-code is assigned to any row in Column 2 in place of a case mix diagnosis it may be necessary to complete optionalitem M1024 Payment Diagnoses (Columns 3 and 4) See OASIS-C Guidance Manual
guidelines enter the diagnosis descriptions and the ICD-9-C M codes in the same row in Columns 3 and 4 For exampleif the case mix diagnosis is a manifestation code record the diagnosis description and ICD-9-C M code for the underlying condition in Column 3 of that rowand the diagnosis description and ICD-9-CM code for the manifestation in Column 4 of that row Otherwise leave Column 4 blank in that row
(M1024) Payment Diagnoses (OPTIONAL)(M1020) Primary Diagnosis amp (M1022) Other DiagnosesCOLUMN 1 COLUMN 2 COLUMN 4
ICD-9-CM and symptom controlrating for each condition Notethat the sequencing of these
ratings may not match thesequencing of the diagnoses
Complete only if the V-code inColumn 2 is reported in place of a casemix diagnosis that is a multiple codingsituation (eg a manifestation code)
Diagnoses (Sequencing of diagnoses should reflect the seriousness of each condition andsupport the disciplines and services provided)
Description ICD-9-CM
(M1020) Primary Diagnosis
a
(V- or E-codes NOT allowed)
a
(V- or E-codes NOT allowed)
a
)(
b
(V- or E-codes are allowed) (V- or E-codes NOT allowed)
b
( )
(V- or E-codes NOT allowed)
b
)( c
Date OE
C
( )
C
)(
d
Date OE
d ( )
4210 3
d
( )
d
e
Date OE
e ( )
421 30
e
( )
e
)( f
Date OE
f f
ICD-9-CM Surgical Procedure
Date )(
Date )(
Page 3 of 20
Patient Name Med Record
wwwpnsystemcom 3058185940 The Outcome and Assessment Information Set (OASIS) is the intellectual property of the Center for Health Services and Policy Research Denver Colorado It is used with permission Expiration date 7312012
Column 4 (OPTIONAL) If a V-code in Column 2 is reported in place of a case mix diagnosis that requires multiple diagnosis codes under ICD-9-C M coding
COLUMN 3
Complete if a V-code is assignedunder certain circumstances to
Column 2 in place of acase mix diagnosis
DescriptionICD-9-CM
Symptom Control Rating Description ICD-9-CM
11
Date OE
Date OE
(M1022) Other Diagnoses 13
1212
( )
( )
f ( )
1 2 40 3
a ( )
1 2 40 3
b ( )
1 2 40 3
c ( )
1 2 40 3
(V-codes are allowed)
)(
)(
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PATIENT HISTORY AND DIAGNOSES (Contd)MAIN REASON FOR HOME HEALTH CARE
HOMEBOUND REASON
Needs assistance for all activities (ADLs)
Requires assistance to ambulateDecreased Range of MotionGeneralized Weakness
Confusion unable to go out of home alone
Severe SOB SOB upon exertion amb ____ feet
Unable to safely leave home without assistance
Medical restrictions
Dependent upon adaptive device(s)
PREVIOUS HISTORY ANDOR PREVIOUS OUTCOMES (Reference M1000 M1005 M1010 and M1012)
Cardiac
Diabetes
HypertensionRespiratory
Cancer (site
Fractures (siteOsteoporosisOsteoarthritis
)
Infection
Immunosuppressed
Open Wound (site
Surgeries (site
Other (specify)
IMMUNIZATIONS Check if current within last 12 months H1N1Influenzaflu regular seasonalOtherFollowing immunization guidelines Pneumonia Tetanus
Pending or NeededPRIOR HOSPITALIZATIONS (in the last six months) No Yes Number of timesReason (s) Date(s)
(M1030) Therapies the patient receives at home (Mark all that apply) 1 - Intravenous or infusion therapy (excludes TPN) 2 - Parenteral nutrition (TPN or lipids) 3 - Enteral nutrition (nasogastric gastrostomy jejunostomy or any
other artificial entry into the alimentary canal) 4 - None of the above
(M1032) Risk for Hospitalization Which of the following signs orsymptoms characterize this patient as at risk for hospitalization
(Mark all that apply)1 - Recent decline in mental emotional or behavioral status2 - Multiple hospitalizations (2 or more) in the past 12 months
113 - History of falls (2 or more falls - or any fall with an injury - in thepast year)
4 -Taking five or more medications(M1036) Risk Factors either present or past likely to affect current
health status andor outcome (Mark all that apply)5 - Frailty indicators eg weight loss self-reported exhaustion6 - Other
1 - Smoking7 - None of the above2 - Obesity(M1034) Overall Status Which description best fits3 - Alcohol dependencythe patientrsquos overall status (Check one)4 - Drug dependency0 -The patient is stable with no heightened risk(s) for serious
complications and death (beyond those typical of the 5 - None of the abovepatientrsquos age) 6 - UK- Unknown
1 - The patient is temporarily facing high health risk(s) but is likely toreturn to being stable without heightened risk(s) for serious complicationsand death (beyond those typical of the patientrsquos age)
Comments (if needed)
2 - The patient is likely to remain in fragile health and have ongoinghigh risk(s) of serious complications and death
3 - The patient has serious progressive conditions that could leadto death within a year
UK - The patients situation is unknown or unclear
LIVING ARRANGEMENTS(M1100) Patient Living Situation Which of the following best describes the patients residential circumstance and availability of assistance
(Check one box only)
Availability of Assistance
Occasional No AssistanceAround the Clock Regular Daytime Regular NighttimeLiving Arrangement AvailableShort-term Assistance
a Patient lives alone 01 02 03 04 05b Patient lives with other
person(s) in the home 06 07 08 09 10
c Patient lives in congregatesituation (eg assisted living) 1 1 12 13 14 15
Patient Name Med Record
Page 4 of 20
wwwpnsystemcom 3058185940 The Outcome and Assessment Information Set (OASIS) is the intellectual property of the Center for Health Services and Policy Research Denver Colorado It is used with permission Expiration date 7312012
(Mark all that apply)
Other (specify)
Needs assist of 1-2 persons
Bedbound (PartialComplete)
MobilityAmbulatory device(s) used
Unsteady Gait18A
) )
Decubitus (site
Insulin DependentNon Insulin Dependent
))
Gastrointestinal Genitourinary
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LIVING ARRANGEMENTS (Contd) SENSORY STATUS HEARING
Yes N o
MOUTH
Other family member(CG) available to help patient with care safely administration of injection procedures
(M1210) Ability to Hear (with hearing aid or hearing appliance if normallyused)
0 - Adequate hears normal conversation without difficulty
Other agencies involved in care
1- Mildly to Moderately Impaired difficulty hearing in someenvironments or speaker may need to increase volume or speakdistinctly
2- Severely Impaired absence of useful hearing
SENSORY STATUS VISION
UK - Unable to assess hearing
(M1200) Vision (with corrective lenses if the patient usually wears them)
No Problem
0 - Normal vision sees adequately in most situations can seemedication labels newsprint
R LHearing aidDeaf R LHOH R LVertigo Tinnitus R L
1 - Partially impaired cannot see medication labels or newsprint buton see obstacles in path and the surrounding layout can countfingers at arms length
(specify)Other
2 - Severely impaired cannot locate objects without hearing or touchingthem or patient nonresponsive
Glasses Glaucoma JaundiceContacts R L Blurred vision
Ptosis
SPEECH and ORAL (VERBAL) CONTENTEXPRESSION
Prosthesis R L OtherLegally Blind RL
(M1220) Understanding of Verbal Content in patients own language(with hearing aid or device if used)
InfectionsCataract surgery Site
0 - Understands clear comprehension without cues or repetitions
Date
1- Usually Understands understands most conversations butmisses some partintent of message Requires cues at times tounderstand
Is there any function safety impact in the patient due to impaired vision(explain)
2 - Sometimes Understands understands only basic conversationsor simple direct phrases Frequently requires cues tounderstand
3 - RarelyNever UnderstandsUK - Unable to assess understanding
NOSE
(M1230) Speech and Oral (Verbal) Expression of Language(in patients own language)
No Problem
0 - Expresses complex ideas feelings and needs clearly completely
Congestion Loss of smellEpistaxis Sinus problem
and easily in all situations with no observable impairment
Other (specify)
1 - Minimal difficulty in expressing ideas and needs (may take extratime makes occasional errors in word choice grammar or speechintelligibility needs minimal prompting or assistance)
2 - Expresses simple ideas or needs with moderate difficulty (needsprompting or assistance errors in word choice organization orspeech intelligibility) Speaks in phrases or short sentences
THROAT
3 - Has severe difficulty expressing basic ideas or needs and requires
No Problem
maximal assistance or guessing by listener Speech limited tosingle words or short phrases
Dysphagia HoarsenessLesions explain
Sore throat
Other (specify)
4 - Unable to express basic needs even with maximal prompting orassistance but is not comatose or unresponsive (eg speech isnonsensical or unintelligible)
5 - Patient nonresponsive or unable to speak
Page 5 of 20
Patient Name Med Record
wwwpnsystemcom 3058185940 The Outcome and Assessment Information Set (OASIS) is the intellectual property of the Center for Health Services and Policy Research Denver Colorado It is used with permission Expiration date 7312012
Primary Caregiver (CG) Significant otherName
Phone number if different from patient
Relationshiphealth statusability to help
Make medical care decisions for the patient
Specify
No Problem
Other eyes surgery SiteDate
Cataract R L
Any nose surgeryDate
Any ears surgeryprocedureDate
Dentures (mark) Upper Lower Partial
MassesTumors site ________________________
Gingivitis Ulcerations Toothache
No Problem
Other (specify)
Any surgeryprocedureDate
Any paid help explain
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PAIN
Occasionally ContinuousIntermittent
Intensity (using scales below)Wong-Baker FACES Pain Rating Scale
Movement Ambulation ImmobilityWhat makes pain worse
Other
Is there a regular pattern to the pain (explain)
Change positionHeat IceunguentWhat relief pain
EntertainmentMedicationRestRelaxation
NO HURT HURTS HURTS HURTS HURTS HURTSLITTLE BIT LITTLE MORE EVEN MORE WHOLE LOT WORSE
Other
2
NeverIf taken medication how often is needed
0 4 6 8 10
N o Moderate Worst
More than 3 timesdayLess than daily
2-3 timesday
Pain Pain Possible Pain
Occasionally Continuously IntermittentDoes the pain radiate
NoYesCurrent pain control medications adequateComment
Yes N o
0-10 Scale (patient reporting)
Implications Care Plan
FACES Scale (Observed)Collected using
StaffPatientHas the physician been notified by theWhat was the outcome
ENDOCRINE STATUS
No Problem
Diabetes Type I Juvenile Type II OnsetExacerbation dateDietOral control (specify)INSULIN dosage frequency scale explain
Self NurseCaregiverFamilyAdministered byOther
Any symptoms present (circle)
Mark Todays visit PatientCaregiver reported
Lab slip
A1c _______ mgdL DateTimeBS
Pain Assessment site 1 site 3
Location site
New Onset Exacerbation
Present level (0-10)
Pain type (aching burningradiating neuralgia etc)Feeling of pain internal external acute chronic
Before meal Postprandial Random HSFBSPatientCaregiver ReportBlood sugar ranges
Monitored byFrequency
Able to use Glucometer
Diabetes Management Problems (explain)
Intolerance to heatcold
Fatigue
Enlarged thyroid (hyperhypothyroid)Other Endocrine problems
(M1240) Has this patient had a formal Pain Assessment using astandardized pain assessment tool (appropriate to the patients ability tocommunicate the severity of pain)
Anemia (specify type if known)
Bleeding problems GI GU GYN unknown Hemophilia
Other
0 - No standardized assessment conducted1 - Yes and it does not indicate severe pain
SKIN INTEGUMENTARY STATUS
2 - Yes and it indicates severe pain
No Problem
(M1242) Frequency of Pain Interfering with patients activity or
Mark all applicable skin conditions listed below
movement
Turgor Good Poor
0 - Patient has no pain
Itch Rash Dry Scaling RednessBruises Ecchymosis Pallor Jaundice
1 - Patient has pain that does not interfere with activity or movement2 - Less often than daily
Other (specify)
3 - Daily but not constantly4 -All of the time
Page 6 of 20
How does the pain interfere with their functionalactivity level ADLs(explain)
QA
site 2
Patient Name Med Record
wwwpnsystemcom 3058185940 The Outcome and Assessment Information Set (OASIS) is the intellectual property of the Center for Health Services and Policy Research Denver Colorado It is used with permission Expiration date 7312012
No Problem
Best Pain Scale 0-10
Worst Pain Scale 0-10
Frequency
NoYesPatient complains about pain
Pain is worse morning afternoon evening nights
NON-VERBAL INDICATORS Afraid to moveCryingGuarding MoaningOther
SleepTime at Bed Minimal activityTransfer
MassageTherapy Walk Go to bed
Daily
Yes N o
Since
Hyperglycemia Polyuria Glycosuria PolydipsiaHypoglycemia Sweats Weak Faint Stupor Polyphagia
Self CaregiverFamily OtherNurse
HEMATOLOGY IMMUNOLOGIC STATUS
Immunodeficiency problems (explain)
No Problem
From Hockenberry MJ Wilson D Winkelstein ML Wongs Essentials of Pediatric Nursing ed 7 St Louis 2005 p 1259 Used with permission Copyright Mosby
Explain to the person that each face is for a person who feels happy because he has no pain (hurt) or sad because he has some or a lot of pain Face 0 is very happy because he doesnt hurt at all Face 1 hurts just a little bit Face 2 hurts a little more Face 3 hurts even more Face 4 hurts a whole lot Face 5 hurts as much as you can imagine although you don t have to be crying to feel this bad Ask the person to choose which face that best describes how he is feeling
Frequently
Does one medication relieve pain better than another If yes which one
Pain control treatmentmeds Side effect (mark) Nausea
Confusion OtherSleepy Vomiting
Frequently
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PATIENT HISTORY AND DIAGNOSES (Contd)(M1020M1022M1024) Diagnoses Symptom Control and Payment Diagnoses List each diagnosis for which the patient is receiving home care(Column 1) and enter its ICD-9-CM code at the level of highest specificity (no surgicalprocedure codes) (Column 2) Diagnoses are listed in the orderthat best reflect the seriousness of each condition and support the disciplines and services provided Rate the degree of symptom control for eachcondition (Column 2) Choose one value that represents the degree of symptom control appropriate for each diagnosis V-codes (for M1020 or M1022)or E-codes (for M1022 only) may be used ICD-9-CM sequencing requirements must be followed if multiple coding is indicated for any diagnoses If aV-code is reported in place of a case mix diagnosis then optional item M1024 Payment Diagnoses (Columns 3 and 4) may be completed A case mixdiagnosis is a diagnosis that determines the Medicare PPS case mix group Do not assign symptom control ratings for V- or E-codesCode each row according to the following directions for each column
Column 1 Enter the description of the diagnosisColumn 2 Enter the ICD-9-CM code for the diagnosis described in Column 1
Rate the degree of symptom control for the condition listed in Column 1 using the following scale0 - Asymptomatic no treatment needed at this time1 - Symptoms well controlled with current therapy2 - Symptoms controlled with difficulty affecting daily functioning patient needs ongoing monitoring3 - Symptoms poorly controlled patient needs frequent adjustment in treatment and dose monitoring4 - Symptoms poorly controlled history of re-hospitalizations
Note that in Column 2 the rating for symptom control of each diagnosis should be used to determine the sequencing of the diagnoseslisted in Column 1 These are separate items and sequencing may not coincide Sequencing of diagnoses should reflect the seriousnessof each condition and support the disciplines and services provided
Column 3 (OPTIONAL) If a V-code is assigned to any row in Column 2 in place of a case mix diagnosis it may be necessary to complete optionalitem M1024 Payment Diagnoses (Columns 3 and 4) See OASIS-C Guidance Manual
guidelines enter the diagnosis descriptions and the ICD-9-C M codes in the same row in Columns 3 and 4 For exampleif the case mix diagnosis is a manifestation code record the diagnosis description and ICD-9-C M code for the underlying condition in Column 3 of that rowand the diagnosis description and ICD-9-CM code for the manifestation in Column 4 of that row Otherwise leave Column 4 blank in that row
(M1024) Payment Diagnoses (OPTIONAL)(M1020) Primary Diagnosis amp (M1022) Other DiagnosesCOLUMN 1 COLUMN 2 COLUMN 4
ICD-9-CM and symptom controlrating for each condition Notethat the sequencing of these
ratings may not match thesequencing of the diagnoses
Complete only if the V-code inColumn 2 is reported in place of a casemix diagnosis that is a multiple codingsituation (eg a manifestation code)
Diagnoses (Sequencing of diagnoses should reflect the seriousness of each condition andsupport the disciplines and services provided)
Description ICD-9-CM
(M1020) Primary Diagnosis
a
(V- or E-codes NOT allowed)
a
(V- or E-codes NOT allowed)
a
)(
b
(V- or E-codes are allowed) (V- or E-codes NOT allowed)
b
( )
(V- or E-codes NOT allowed)
b
)( c
Date OE
C
( )
C
)(
d
Date OE
d ( )
4210 3
d
( )
d
e
Date OE
e ( )
421 30
e
( )
e
)( f
Date OE
f f
ICD-9-CM Surgical Procedure
Date )(
Date )(
Page 3 of 20
Patient Name Med Record
wwwpnsystemcom 3058185940 The Outcome and Assessment Information Set (OASIS) is the intellectual property of the Center for Health Services and Policy Research Denver Colorado It is used with permission Expiration date 7312012
Column 4 (OPTIONAL) If a V-code in Column 2 is reported in place of a case mix diagnosis that requires multiple diagnosis codes under ICD-9-C M coding
COLUMN 3
Complete if a V-code is assignedunder certain circumstances to
Column 2 in place of acase mix diagnosis
DescriptionICD-9-CM
Symptom Control Rating Description ICD-9-CM
11
Date OE
Date OE
(M1022) Other Diagnoses 13
1212
( )
( )
f ( )
1 2 40 3
a ( )
1 2 40 3
b ( )
1 2 40 3
c ( )
1 2 40 3
(V-codes are allowed)
)(
)(
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PATIENT HISTORY AND DIAGNOSES (Contd)MAIN REASON FOR HOME HEALTH CARE
HOMEBOUND REASON
Needs assistance for all activities (ADLs)
Requires assistance to ambulateDecreased Range of MotionGeneralized Weakness
Confusion unable to go out of home alone
Severe SOB SOB upon exertion amb ____ feet
Unable to safely leave home without assistance
Medical restrictions
Dependent upon adaptive device(s)
PREVIOUS HISTORY ANDOR PREVIOUS OUTCOMES (Reference M1000 M1005 M1010 and M1012)
Cardiac
Diabetes
HypertensionRespiratory
Cancer (site
Fractures (siteOsteoporosisOsteoarthritis
)
Infection
Immunosuppressed
Open Wound (site
Surgeries (site
Other (specify)
IMMUNIZATIONS Check if current within last 12 months H1N1Influenzaflu regular seasonalOtherFollowing immunization guidelines Pneumonia Tetanus
Pending or NeededPRIOR HOSPITALIZATIONS (in the last six months) No Yes Number of timesReason (s) Date(s)
(M1030) Therapies the patient receives at home (Mark all that apply) 1 - Intravenous or infusion therapy (excludes TPN) 2 - Parenteral nutrition (TPN or lipids) 3 - Enteral nutrition (nasogastric gastrostomy jejunostomy or any
other artificial entry into the alimentary canal) 4 - None of the above
(M1032) Risk for Hospitalization Which of the following signs orsymptoms characterize this patient as at risk for hospitalization
(Mark all that apply)1 - Recent decline in mental emotional or behavioral status2 - Multiple hospitalizations (2 or more) in the past 12 months
113 - History of falls (2 or more falls - or any fall with an injury - in thepast year)
4 -Taking five or more medications(M1036) Risk Factors either present or past likely to affect current
health status andor outcome (Mark all that apply)5 - Frailty indicators eg weight loss self-reported exhaustion6 - Other
1 - Smoking7 - None of the above2 - Obesity(M1034) Overall Status Which description best fits3 - Alcohol dependencythe patientrsquos overall status (Check one)4 - Drug dependency0 -The patient is stable with no heightened risk(s) for serious
complications and death (beyond those typical of the 5 - None of the abovepatientrsquos age) 6 - UK- Unknown
1 - The patient is temporarily facing high health risk(s) but is likely toreturn to being stable without heightened risk(s) for serious complicationsand death (beyond those typical of the patientrsquos age)
Comments (if needed)
2 - The patient is likely to remain in fragile health and have ongoinghigh risk(s) of serious complications and death
3 - The patient has serious progressive conditions that could leadto death within a year
UK - The patients situation is unknown or unclear
LIVING ARRANGEMENTS(M1100) Patient Living Situation Which of the following best describes the patients residential circumstance and availability of assistance
(Check one box only)
Availability of Assistance
Occasional No AssistanceAround the Clock Regular Daytime Regular NighttimeLiving Arrangement AvailableShort-term Assistance
a Patient lives alone 01 02 03 04 05b Patient lives with other
person(s) in the home 06 07 08 09 10
c Patient lives in congregatesituation (eg assisted living) 1 1 12 13 14 15
Patient Name Med Record
Page 4 of 20
wwwpnsystemcom 3058185940 The Outcome and Assessment Information Set (OASIS) is the intellectual property of the Center for Health Services and Policy Research Denver Colorado It is used with permission Expiration date 7312012
(Mark all that apply)
Other (specify)
Needs assist of 1-2 persons
Bedbound (PartialComplete)
MobilityAmbulatory device(s) used
Unsteady Gait18A
) )
Decubitus (site
Insulin DependentNon Insulin Dependent
))
Gastrointestinal Genitourinary
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LIVING ARRANGEMENTS (Contd) SENSORY STATUS HEARING
Yes N o
MOUTH
Other family member(CG) available to help patient with care safely administration of injection procedures
(M1210) Ability to Hear (with hearing aid or hearing appliance if normallyused)
0 - Adequate hears normal conversation without difficulty
Other agencies involved in care
1- Mildly to Moderately Impaired difficulty hearing in someenvironments or speaker may need to increase volume or speakdistinctly
2- Severely Impaired absence of useful hearing
SENSORY STATUS VISION
UK - Unable to assess hearing
(M1200) Vision (with corrective lenses if the patient usually wears them)
No Problem
0 - Normal vision sees adequately in most situations can seemedication labels newsprint
R LHearing aidDeaf R LHOH R LVertigo Tinnitus R L
1 - Partially impaired cannot see medication labels or newsprint buton see obstacles in path and the surrounding layout can countfingers at arms length
(specify)Other
2 - Severely impaired cannot locate objects without hearing or touchingthem or patient nonresponsive
Glasses Glaucoma JaundiceContacts R L Blurred vision
Ptosis
SPEECH and ORAL (VERBAL) CONTENTEXPRESSION
Prosthesis R L OtherLegally Blind RL
(M1220) Understanding of Verbal Content in patients own language(with hearing aid or device if used)
InfectionsCataract surgery Site
0 - Understands clear comprehension without cues or repetitions
Date
1- Usually Understands understands most conversations butmisses some partintent of message Requires cues at times tounderstand
Is there any function safety impact in the patient due to impaired vision(explain)
2 - Sometimes Understands understands only basic conversationsor simple direct phrases Frequently requires cues tounderstand
3 - RarelyNever UnderstandsUK - Unable to assess understanding
NOSE
(M1230) Speech and Oral (Verbal) Expression of Language(in patients own language)
No Problem
0 - Expresses complex ideas feelings and needs clearly completely
Congestion Loss of smellEpistaxis Sinus problem
and easily in all situations with no observable impairment
Other (specify)
1 - Minimal difficulty in expressing ideas and needs (may take extratime makes occasional errors in word choice grammar or speechintelligibility needs minimal prompting or assistance)
2 - Expresses simple ideas or needs with moderate difficulty (needsprompting or assistance errors in word choice organization orspeech intelligibility) Speaks in phrases or short sentences
THROAT
3 - Has severe difficulty expressing basic ideas or needs and requires
No Problem
maximal assistance or guessing by listener Speech limited tosingle words or short phrases
Dysphagia HoarsenessLesions explain
Sore throat
Other (specify)
4 - Unable to express basic needs even with maximal prompting orassistance but is not comatose or unresponsive (eg speech isnonsensical or unintelligible)
5 - Patient nonresponsive or unable to speak
Page 5 of 20
Patient Name Med Record
wwwpnsystemcom 3058185940 The Outcome and Assessment Information Set (OASIS) is the intellectual property of the Center for Health Services and Policy Research Denver Colorado It is used with permission Expiration date 7312012
Primary Caregiver (CG) Significant otherName
Phone number if different from patient
Relationshiphealth statusability to help
Make medical care decisions for the patient
Specify
No Problem
Other eyes surgery SiteDate
Cataract R L
Any nose surgeryDate
Any ears surgeryprocedureDate
Dentures (mark) Upper Lower Partial
MassesTumors site ________________________
Gingivitis Ulcerations Toothache
No Problem
Other (specify)
Any surgeryprocedureDate
Any paid help explain
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PAIN
Occasionally ContinuousIntermittent
Intensity (using scales below)Wong-Baker FACES Pain Rating Scale
Movement Ambulation ImmobilityWhat makes pain worse
Other
Is there a regular pattern to the pain (explain)
Change positionHeat IceunguentWhat relief pain
EntertainmentMedicationRestRelaxation
NO HURT HURTS HURTS HURTS HURTS HURTSLITTLE BIT LITTLE MORE EVEN MORE WHOLE LOT WORSE
Other
2
NeverIf taken medication how often is needed
0 4 6 8 10
N o Moderate Worst
More than 3 timesdayLess than daily
2-3 timesday
Pain Pain Possible Pain
Occasionally Continuously IntermittentDoes the pain radiate
NoYesCurrent pain control medications adequateComment
Yes N o
0-10 Scale (patient reporting)
Implications Care Plan
FACES Scale (Observed)Collected using
StaffPatientHas the physician been notified by theWhat was the outcome
ENDOCRINE STATUS
No Problem
Diabetes Type I Juvenile Type II OnsetExacerbation dateDietOral control (specify)INSULIN dosage frequency scale explain
Self NurseCaregiverFamilyAdministered byOther
Any symptoms present (circle)
Mark Todays visit PatientCaregiver reported
Lab slip
A1c _______ mgdL DateTimeBS
Pain Assessment site 1 site 3
Location site
New Onset Exacerbation
Present level (0-10)
Pain type (aching burningradiating neuralgia etc)Feeling of pain internal external acute chronic
Before meal Postprandial Random HSFBSPatientCaregiver ReportBlood sugar ranges
Monitored byFrequency
Able to use Glucometer
Diabetes Management Problems (explain)
Intolerance to heatcold
Fatigue
Enlarged thyroid (hyperhypothyroid)Other Endocrine problems
(M1240) Has this patient had a formal Pain Assessment using astandardized pain assessment tool (appropriate to the patients ability tocommunicate the severity of pain)
Anemia (specify type if known)
Bleeding problems GI GU GYN unknown Hemophilia
Other
0 - No standardized assessment conducted1 - Yes and it does not indicate severe pain
SKIN INTEGUMENTARY STATUS
2 - Yes and it indicates severe pain
No Problem
(M1242) Frequency of Pain Interfering with patients activity or
Mark all applicable skin conditions listed below
movement
Turgor Good Poor
0 - Patient has no pain
Itch Rash Dry Scaling RednessBruises Ecchymosis Pallor Jaundice
1 - Patient has pain that does not interfere with activity or movement2 - Less often than daily
Other (specify)
3 - Daily but not constantly4 -All of the time
Page 6 of 20
How does the pain interfere with their functionalactivity level ADLs(explain)
QA
site 2
Patient Name Med Record
wwwpnsystemcom 3058185940 The Outcome and Assessment Information Set (OASIS) is the intellectual property of the Center for Health Services and Policy Research Denver Colorado It is used with permission Expiration date 7312012
No Problem
Best Pain Scale 0-10
Worst Pain Scale 0-10
Frequency
NoYesPatient complains about pain
Pain is worse morning afternoon evening nights
NON-VERBAL INDICATORS Afraid to moveCryingGuarding MoaningOther
SleepTime at Bed Minimal activityTransfer
MassageTherapy Walk Go to bed
Daily
Yes N o
Since
Hyperglycemia Polyuria Glycosuria PolydipsiaHypoglycemia Sweats Weak Faint Stupor Polyphagia
Self CaregiverFamily OtherNurse
HEMATOLOGY IMMUNOLOGIC STATUS
Immunodeficiency problems (explain)
No Problem
From Hockenberry MJ Wilson D Winkelstein ML Wongs Essentials of Pediatric Nursing ed 7 St Louis 2005 p 1259 Used with permission Copyright Mosby
Explain to the person that each face is for a person who feels happy because he has no pain (hurt) or sad because he has some or a lot of pain Face 0 is very happy because he doesnt hurt at all Face 1 hurts just a little bit Face 2 hurts a little more Face 3 hurts even more Face 4 hurts a whole lot Face 5 hurts as much as you can imagine although you don t have to be crying to feel this bad Ask the person to choose which face that best describes how he is feeling
Frequently
Does one medication relieve pain better than another If yes which one
Pain control treatmentmeds Side effect (mark) Nausea
Confusion OtherSleepy Vomiting
Frequently
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PATIENT HISTORY AND DIAGNOSES (Contd)MAIN REASON FOR HOME HEALTH CARE
HOMEBOUND REASON
Needs assistance for all activities (ADLs)
Requires assistance to ambulateDecreased Range of MotionGeneralized Weakness
Confusion unable to go out of home alone
Severe SOB SOB upon exertion amb ____ feet
Unable to safely leave home without assistance
Medical restrictions
Dependent upon adaptive device(s)
PREVIOUS HISTORY ANDOR PREVIOUS OUTCOMES (Reference M1000 M1005 M1010 and M1012)
Cardiac
Diabetes
HypertensionRespiratory
Cancer (site
Fractures (siteOsteoporosisOsteoarthritis
)
Infection
Immunosuppressed
Open Wound (site
Surgeries (site
Other (specify)
IMMUNIZATIONS Check if current within last 12 months H1N1Influenzaflu regular seasonalOtherFollowing immunization guidelines Pneumonia Tetanus
Pending or NeededPRIOR HOSPITALIZATIONS (in the last six months) No Yes Number of timesReason (s) Date(s)
(M1030) Therapies the patient receives at home (Mark all that apply) 1 - Intravenous or infusion therapy (excludes TPN) 2 - Parenteral nutrition (TPN or lipids) 3 - Enteral nutrition (nasogastric gastrostomy jejunostomy or any
other artificial entry into the alimentary canal) 4 - None of the above
(M1032) Risk for Hospitalization Which of the following signs orsymptoms characterize this patient as at risk for hospitalization
(Mark all that apply)1 - Recent decline in mental emotional or behavioral status2 - Multiple hospitalizations (2 or more) in the past 12 months
113 - History of falls (2 or more falls - or any fall with an injury - in thepast year)
4 -Taking five or more medications(M1036) Risk Factors either present or past likely to affect current
health status andor outcome (Mark all that apply)5 - Frailty indicators eg weight loss self-reported exhaustion6 - Other
1 - Smoking7 - None of the above2 - Obesity(M1034) Overall Status Which description best fits3 - Alcohol dependencythe patientrsquos overall status (Check one)4 - Drug dependency0 -The patient is stable with no heightened risk(s) for serious
complications and death (beyond those typical of the 5 - None of the abovepatientrsquos age) 6 - UK- Unknown
1 - The patient is temporarily facing high health risk(s) but is likely toreturn to being stable without heightened risk(s) for serious complicationsand death (beyond those typical of the patientrsquos age)
Comments (if needed)
2 - The patient is likely to remain in fragile health and have ongoinghigh risk(s) of serious complications and death
3 - The patient has serious progressive conditions that could leadto death within a year
UK - The patients situation is unknown or unclear
LIVING ARRANGEMENTS(M1100) Patient Living Situation Which of the following best describes the patients residential circumstance and availability of assistance
(Check one box only)
Availability of Assistance
Occasional No AssistanceAround the Clock Regular Daytime Regular NighttimeLiving Arrangement AvailableShort-term Assistance
a Patient lives alone 01 02 03 04 05b Patient lives with other
person(s) in the home 06 07 08 09 10
c Patient lives in congregatesituation (eg assisted living) 1 1 12 13 14 15
Patient Name Med Record
Page 4 of 20
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(Mark all that apply)
Other (specify)
Needs assist of 1-2 persons
Bedbound (PartialComplete)
MobilityAmbulatory device(s) used
Unsteady Gait18A
) )
Decubitus (site
Insulin DependentNon Insulin Dependent
))
Gastrointestinal Genitourinary
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LIVING ARRANGEMENTS (Contd) SENSORY STATUS HEARING
Yes N o
MOUTH
Other family member(CG) available to help patient with care safely administration of injection procedures
(M1210) Ability to Hear (with hearing aid or hearing appliance if normallyused)
0 - Adequate hears normal conversation without difficulty
Other agencies involved in care
1- Mildly to Moderately Impaired difficulty hearing in someenvironments or speaker may need to increase volume or speakdistinctly
2- Severely Impaired absence of useful hearing
SENSORY STATUS VISION
UK - Unable to assess hearing
(M1200) Vision (with corrective lenses if the patient usually wears them)
No Problem
0 - Normal vision sees adequately in most situations can seemedication labels newsprint
R LHearing aidDeaf R LHOH R LVertigo Tinnitus R L
1 - Partially impaired cannot see medication labels or newsprint buton see obstacles in path and the surrounding layout can countfingers at arms length
(specify)Other
2 - Severely impaired cannot locate objects without hearing or touchingthem or patient nonresponsive
Glasses Glaucoma JaundiceContacts R L Blurred vision
Ptosis
SPEECH and ORAL (VERBAL) CONTENTEXPRESSION
Prosthesis R L OtherLegally Blind RL
(M1220) Understanding of Verbal Content in patients own language(with hearing aid or device if used)
InfectionsCataract surgery Site
0 - Understands clear comprehension without cues or repetitions
Date
1- Usually Understands understands most conversations butmisses some partintent of message Requires cues at times tounderstand
Is there any function safety impact in the patient due to impaired vision(explain)
2 - Sometimes Understands understands only basic conversationsor simple direct phrases Frequently requires cues tounderstand
3 - RarelyNever UnderstandsUK - Unable to assess understanding
NOSE
(M1230) Speech and Oral (Verbal) Expression of Language(in patients own language)
No Problem
0 - Expresses complex ideas feelings and needs clearly completely
Congestion Loss of smellEpistaxis Sinus problem
and easily in all situations with no observable impairment
Other (specify)
1 - Minimal difficulty in expressing ideas and needs (may take extratime makes occasional errors in word choice grammar or speechintelligibility needs minimal prompting or assistance)
2 - Expresses simple ideas or needs with moderate difficulty (needsprompting or assistance errors in word choice organization orspeech intelligibility) Speaks in phrases or short sentences
THROAT
3 - Has severe difficulty expressing basic ideas or needs and requires
No Problem
maximal assistance or guessing by listener Speech limited tosingle words or short phrases
Dysphagia HoarsenessLesions explain
Sore throat
Other (specify)
4 - Unable to express basic needs even with maximal prompting orassistance but is not comatose or unresponsive (eg speech isnonsensical or unintelligible)
5 - Patient nonresponsive or unable to speak
Page 5 of 20
Patient Name Med Record
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Primary Caregiver (CG) Significant otherName
Phone number if different from patient
Relationshiphealth statusability to help
Make medical care decisions for the patient
Specify
No Problem
Other eyes surgery SiteDate
Cataract R L
Any nose surgeryDate
Any ears surgeryprocedureDate
Dentures (mark) Upper Lower Partial
MassesTumors site ________________________
Gingivitis Ulcerations Toothache
No Problem
Other (specify)
Any surgeryprocedureDate
Any paid help explain
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PAIN
Occasionally ContinuousIntermittent
Intensity (using scales below)Wong-Baker FACES Pain Rating Scale
Movement Ambulation ImmobilityWhat makes pain worse
Other
Is there a regular pattern to the pain (explain)
Change positionHeat IceunguentWhat relief pain
EntertainmentMedicationRestRelaxation
NO HURT HURTS HURTS HURTS HURTS HURTSLITTLE BIT LITTLE MORE EVEN MORE WHOLE LOT WORSE
Other
2
NeverIf taken medication how often is needed
0 4 6 8 10
N o Moderate Worst
More than 3 timesdayLess than daily
2-3 timesday
Pain Pain Possible Pain
Occasionally Continuously IntermittentDoes the pain radiate
NoYesCurrent pain control medications adequateComment
Yes N o
0-10 Scale (patient reporting)
Implications Care Plan
FACES Scale (Observed)Collected using
StaffPatientHas the physician been notified by theWhat was the outcome
ENDOCRINE STATUS
No Problem
Diabetes Type I Juvenile Type II OnsetExacerbation dateDietOral control (specify)INSULIN dosage frequency scale explain
Self NurseCaregiverFamilyAdministered byOther
Any symptoms present (circle)
Mark Todays visit PatientCaregiver reported
Lab slip
A1c _______ mgdL DateTimeBS
Pain Assessment site 1 site 3
Location site
New Onset Exacerbation
Present level (0-10)
Pain type (aching burningradiating neuralgia etc)Feeling of pain internal external acute chronic
Before meal Postprandial Random HSFBSPatientCaregiver ReportBlood sugar ranges
Monitored byFrequency
Able to use Glucometer
Diabetes Management Problems (explain)
Intolerance to heatcold
Fatigue
Enlarged thyroid (hyperhypothyroid)Other Endocrine problems
(M1240) Has this patient had a formal Pain Assessment using astandardized pain assessment tool (appropriate to the patients ability tocommunicate the severity of pain)
Anemia (specify type if known)
Bleeding problems GI GU GYN unknown Hemophilia
Other
0 - No standardized assessment conducted1 - Yes and it does not indicate severe pain
SKIN INTEGUMENTARY STATUS
2 - Yes and it indicates severe pain
No Problem
(M1242) Frequency of Pain Interfering with patients activity or
Mark all applicable skin conditions listed below
movement
Turgor Good Poor
0 - Patient has no pain
Itch Rash Dry Scaling RednessBruises Ecchymosis Pallor Jaundice
1 - Patient has pain that does not interfere with activity or movement2 - Less often than daily
Other (specify)
3 - Daily but not constantly4 -All of the time
Page 6 of 20
How does the pain interfere with their functionalactivity level ADLs(explain)
QA
site 2
Patient Name Med Record
wwwpnsystemcom 3058185940 The Outcome and Assessment Information Set (OASIS) is the intellectual property of the Center for Health Services and Policy Research Denver Colorado It is used with permission Expiration date 7312012
No Problem
Best Pain Scale 0-10
Worst Pain Scale 0-10
Frequency
NoYesPatient complains about pain
Pain is worse morning afternoon evening nights
NON-VERBAL INDICATORS Afraid to moveCryingGuarding MoaningOther
SleepTime at Bed Minimal activityTransfer
MassageTherapy Walk Go to bed
Daily
Yes N o
Since
Hyperglycemia Polyuria Glycosuria PolydipsiaHypoglycemia Sweats Weak Faint Stupor Polyphagia
Self CaregiverFamily OtherNurse
HEMATOLOGY IMMUNOLOGIC STATUS
Immunodeficiency problems (explain)
No Problem
From Hockenberry MJ Wilson D Winkelstein ML Wongs Essentials of Pediatric Nursing ed 7 St Louis 2005 p 1259 Used with permission Copyright Mosby
Explain to the person that each face is for a person who feels happy because he has no pain (hurt) or sad because he has some or a lot of pain Face 0 is very happy because he doesnt hurt at all Face 1 hurts just a little bit Face 2 hurts a little more Face 3 hurts even more Face 4 hurts a whole lot Face 5 hurts as much as you can imagine although you don t have to be crying to feel this bad Ask the person to choose which face that best describes how he is feeling
Frequently
Does one medication relieve pain better than another If yes which one
Pain control treatmentmeds Side effect (mark) Nausea
Confusion OtherSleepy Vomiting
Frequently
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LIVING ARRANGEMENTS (Contd) SENSORY STATUS HEARING
Yes N o
MOUTH
Other family member(CG) available to help patient with care safely administration of injection procedures
(M1210) Ability to Hear (with hearing aid or hearing appliance if normallyused)
0 - Adequate hears normal conversation without difficulty
Other agencies involved in care
1- Mildly to Moderately Impaired difficulty hearing in someenvironments or speaker may need to increase volume or speakdistinctly
2- Severely Impaired absence of useful hearing
SENSORY STATUS VISION
UK - Unable to assess hearing
(M1200) Vision (with corrective lenses if the patient usually wears them)
No Problem
0 - Normal vision sees adequately in most situations can seemedication labels newsprint
R LHearing aidDeaf R LHOH R LVertigo Tinnitus R L
1 - Partially impaired cannot see medication labels or newsprint buton see obstacles in path and the surrounding layout can countfingers at arms length
(specify)Other
2 - Severely impaired cannot locate objects without hearing or touchingthem or patient nonresponsive
Glasses Glaucoma JaundiceContacts R L Blurred vision
Ptosis
SPEECH and ORAL (VERBAL) CONTENTEXPRESSION
Prosthesis R L OtherLegally Blind RL
(M1220) Understanding of Verbal Content in patients own language(with hearing aid or device if used)
InfectionsCataract surgery Site
0 - Understands clear comprehension without cues or repetitions
Date
1- Usually Understands understands most conversations butmisses some partintent of message Requires cues at times tounderstand
Is there any function safety impact in the patient due to impaired vision(explain)
2 - Sometimes Understands understands only basic conversationsor simple direct phrases Frequently requires cues tounderstand
3 - RarelyNever UnderstandsUK - Unable to assess understanding
NOSE
(M1230) Speech and Oral (Verbal) Expression of Language(in patients own language)
No Problem
0 - Expresses complex ideas feelings and needs clearly completely
Congestion Loss of smellEpistaxis Sinus problem
and easily in all situations with no observable impairment
Other (specify)
1 - Minimal difficulty in expressing ideas and needs (may take extratime makes occasional errors in word choice grammar or speechintelligibility needs minimal prompting or assistance)
2 - Expresses simple ideas or needs with moderate difficulty (needsprompting or assistance errors in word choice organization orspeech intelligibility) Speaks in phrases or short sentences
THROAT
3 - Has severe difficulty expressing basic ideas or needs and requires
No Problem
maximal assistance or guessing by listener Speech limited tosingle words or short phrases
Dysphagia HoarsenessLesions explain
Sore throat
Other (specify)
4 - Unable to express basic needs even with maximal prompting orassistance but is not comatose or unresponsive (eg speech isnonsensical or unintelligible)
5 - Patient nonresponsive or unable to speak
Page 5 of 20
Patient Name Med Record
wwwpnsystemcom 3058185940 The Outcome and Assessment Information Set (OASIS) is the intellectual property of the Center for Health Services and Policy Research Denver Colorado It is used with permission Expiration date 7312012
Primary Caregiver (CG) Significant otherName
Phone number if different from patient
Relationshiphealth statusability to help
Make medical care decisions for the patient
Specify
No Problem
Other eyes surgery SiteDate
Cataract R L
Any nose surgeryDate
Any ears surgeryprocedureDate
Dentures (mark) Upper Lower Partial
MassesTumors site ________________________
Gingivitis Ulcerations Toothache
No Problem
Other (specify)
Any surgeryprocedureDate
Any paid help explain
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PAIN
Occasionally ContinuousIntermittent
Intensity (using scales below)Wong-Baker FACES Pain Rating Scale
Movement Ambulation ImmobilityWhat makes pain worse
Other
Is there a regular pattern to the pain (explain)
Change positionHeat IceunguentWhat relief pain
EntertainmentMedicationRestRelaxation
NO HURT HURTS HURTS HURTS HURTS HURTSLITTLE BIT LITTLE MORE EVEN MORE WHOLE LOT WORSE
Other
2
NeverIf taken medication how often is needed
0 4 6 8 10
N o Moderate Worst
More than 3 timesdayLess than daily
2-3 timesday
Pain Pain Possible Pain
Occasionally Continuously IntermittentDoes the pain radiate
NoYesCurrent pain control medications adequateComment
Yes N o
0-10 Scale (patient reporting)
Implications Care Plan
FACES Scale (Observed)Collected using
StaffPatientHas the physician been notified by theWhat was the outcome
ENDOCRINE STATUS
No Problem
Diabetes Type I Juvenile Type II OnsetExacerbation dateDietOral control (specify)INSULIN dosage frequency scale explain
Self NurseCaregiverFamilyAdministered byOther
Any symptoms present (circle)
Mark Todays visit PatientCaregiver reported
Lab slip
A1c _______ mgdL DateTimeBS
Pain Assessment site 1 site 3
Location site
New Onset Exacerbation
Present level (0-10)
Pain type (aching burningradiating neuralgia etc)Feeling of pain internal external acute chronic
Before meal Postprandial Random HSFBSPatientCaregiver ReportBlood sugar ranges
Monitored byFrequency
Able to use Glucometer
Diabetes Management Problems (explain)
Intolerance to heatcold
Fatigue
Enlarged thyroid (hyperhypothyroid)Other Endocrine problems
(M1240) Has this patient had a formal Pain Assessment using astandardized pain assessment tool (appropriate to the patients ability tocommunicate the severity of pain)
Anemia (specify type if known)
Bleeding problems GI GU GYN unknown Hemophilia
Other
0 - No standardized assessment conducted1 - Yes and it does not indicate severe pain
SKIN INTEGUMENTARY STATUS
2 - Yes and it indicates severe pain
No Problem
(M1242) Frequency of Pain Interfering with patients activity or
Mark all applicable skin conditions listed below
movement
Turgor Good Poor
0 - Patient has no pain
Itch Rash Dry Scaling RednessBruises Ecchymosis Pallor Jaundice
1 - Patient has pain that does not interfere with activity or movement2 - Less often than daily
Other (specify)
3 - Daily but not constantly4 -All of the time
Page 6 of 20
How does the pain interfere with their functionalactivity level ADLs(explain)
QA
site 2
Patient Name Med Record
wwwpnsystemcom 3058185940 The Outcome and Assessment Information Set (OASIS) is the intellectual property of the Center for Health Services and Policy Research Denver Colorado It is used with permission Expiration date 7312012
No Problem
Best Pain Scale 0-10
Worst Pain Scale 0-10
Frequency
NoYesPatient complains about pain
Pain is worse morning afternoon evening nights
NON-VERBAL INDICATORS Afraid to moveCryingGuarding MoaningOther
SleepTime at Bed Minimal activityTransfer
MassageTherapy Walk Go to bed
Daily
Yes N o
Since
Hyperglycemia Polyuria Glycosuria PolydipsiaHypoglycemia Sweats Weak Faint Stupor Polyphagia
Self CaregiverFamily OtherNurse
HEMATOLOGY IMMUNOLOGIC STATUS
Immunodeficiency problems (explain)
No Problem
From Hockenberry MJ Wilson D Winkelstein ML Wongs Essentials of Pediatric Nursing ed 7 St Louis 2005 p 1259 Used with permission Copyright Mosby
Explain to the person that each face is for a person who feels happy because he has no pain (hurt) or sad because he has some or a lot of pain Face 0 is very happy because he doesnt hurt at all Face 1 hurts just a little bit Face 2 hurts a little more Face 3 hurts even more Face 4 hurts a whole lot Face 5 hurts as much as you can imagine although you don t have to be crying to feel this bad Ask the person to choose which face that best describes how he is feeling
Frequently
Does one medication relieve pain better than another If yes which one
Pain control treatmentmeds Side effect (mark) Nausea
Confusion OtherSleepy Vomiting
Frequently
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PAIN
Occasionally ContinuousIntermittent
Intensity (using scales below)Wong-Baker FACES Pain Rating Scale
Movement Ambulation ImmobilityWhat makes pain worse
Other
Is there a regular pattern to the pain (explain)
Change positionHeat IceunguentWhat relief pain
EntertainmentMedicationRestRelaxation
NO HURT HURTS HURTS HURTS HURTS HURTSLITTLE BIT LITTLE MORE EVEN MORE WHOLE LOT WORSE
Other
2
NeverIf taken medication how often is needed
0 4 6 8 10
N o Moderate Worst
More than 3 timesdayLess than daily
2-3 timesday
Pain Pain Possible Pain
Occasionally Continuously IntermittentDoes the pain radiate
NoYesCurrent pain control medications adequateComment
Yes N o
0-10 Scale (patient reporting)
Implications Care Plan
FACES Scale (Observed)Collected using
StaffPatientHas the physician been notified by theWhat was the outcome
ENDOCRINE STATUS
No Problem
Diabetes Type I Juvenile Type II OnsetExacerbation dateDietOral control (specify)INSULIN dosage frequency scale explain
Self NurseCaregiverFamilyAdministered byOther
Any symptoms present (circle)
Mark Todays visit PatientCaregiver reported
Lab slip
A1c _______ mgdL DateTimeBS
Pain Assessment site 1 site 3
Location site
New Onset Exacerbation
Present level (0-10)
Pain type (aching burningradiating neuralgia etc)Feeling of pain internal external acute chronic
Before meal Postprandial Random HSFBSPatientCaregiver ReportBlood sugar ranges
Monitored byFrequency
Able to use Glucometer
Diabetes Management Problems (explain)
Intolerance to heatcold
Fatigue
Enlarged thyroid (hyperhypothyroid)Other Endocrine problems
(M1240) Has this patient had a formal Pain Assessment using astandardized pain assessment tool (appropriate to the patients ability tocommunicate the severity of pain)
Anemia (specify type if known)
Bleeding problems GI GU GYN unknown Hemophilia
Other
0 - No standardized assessment conducted1 - Yes and it does not indicate severe pain
SKIN INTEGUMENTARY STATUS
2 - Yes and it indicates severe pain
No Problem
(M1242) Frequency of Pain Interfering with patients activity or
Mark all applicable skin conditions listed below
movement
Turgor Good Poor
0 - Patient has no pain
Itch Rash Dry Scaling RednessBruises Ecchymosis Pallor Jaundice
1 - Patient has pain that does not interfere with activity or movement2 - Less often than daily
Other (specify)
3 - Daily but not constantly4 -All of the time
Page 6 of 20
How does the pain interfere with their functionalactivity level ADLs(explain)
QA
site 2
Patient Name Med Record
wwwpnsystemcom 3058185940 The Outcome and Assessment Information Set (OASIS) is the intellectual property of the Center for Health Services and Policy Research Denver Colorado It is used with permission Expiration date 7312012
No Problem
Best Pain Scale 0-10
Worst Pain Scale 0-10
Frequency
NoYesPatient complains about pain
Pain is worse morning afternoon evening nights
NON-VERBAL INDICATORS Afraid to moveCryingGuarding MoaningOther
SleepTime at Bed Minimal activityTransfer
MassageTherapy Walk Go to bed
Daily
Yes N o
Since
Hyperglycemia Polyuria Glycosuria PolydipsiaHypoglycemia Sweats Weak Faint Stupor Polyphagia
Self CaregiverFamily OtherNurse
HEMATOLOGY IMMUNOLOGIC STATUS
Immunodeficiency problems (explain)
No Problem
From Hockenberry MJ Wilson D Winkelstein ML Wongs Essentials of Pediatric Nursing ed 7 St Louis 2005 p 1259 Used with permission Copyright Mosby
Explain to the person that each face is for a person who feels happy because he has no pain (hurt) or sad because he has some or a lot of pain Face 0 is very happy because he doesnt hurt at all Face 1 hurts just a little bit Face 2 hurts a little more Face 3 hurts even more Face 4 hurts a whole lot Face 5 hurts as much as you can imagine although you don t have to be crying to feel this bad Ask the person to choose which face that best describes how he is feeling
Frequently
Does one medication relieve pain better than another If yes which one
Pain control treatmentmeds Side effect (mark) Nausea
Confusion OtherSleepy Vomiting
Frequently
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INTEGUMENTARY STATUS (Contd)(M1300) Pressure Ulcer Assessment Was this patient assessed forRisk of Developing Pressure Ulcers
0 - No assessment conducted [Go to M1306]1 -Yes based on an evaluation of clinical factors eg mobility
incontinence nutrition etc without use of standardized tool2 -Yes using a standardized tool eg Braden Norton other
(M1302) Does this patient have a Risk of Developing Pressure Ulcers0 - No1 -Yes
(M1306) Does this patient have at least one Unhealed Pressure Ulcerat Stage II or Higher or designated as unstageable
0 - No [Go to M1322]1 -Yes
(M1308) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Each Stage(Enter 0 if none excludes Stage 1 pressure ulcers)
Column 1 Column 2Complete at SOCROCFU amp DC Complete at FU amp DC
Stage Description - Unhealed Pressure Ulcers
a Stage II Partial thickness loss of dermis presenting as ashallow open ulcer with red pink wound bed without sloughMay also present as an intact or openruptured serum-filledblister
b Stage III Full thickness tissue loss Subcutaneous fat may bevisible but bone tendon or muscles are not exposed Sloughmay be present but does not obscure the depth of tissue lossMay include undermining and tunneling
d1 Unstageable Known or likely but unstageable due to non-removable dressing or device
Directions for M1310 M1312 and M1314 If the patient has one ormore unhealed (non-epithelialized) Stage III or IV pressure ulcersidentify the Stage III or IV pressure ulcer with the largest surfacedimension (length x width) and record in centimeters If no Stage III orStage IV pressure ulcers go to M1320
(M1320) Status of Most Problematic (Observable) Pressure Ulcer
0 - Newly epithelialized1 - Fully granulating2 - Earlypartial granulation3 - Not healing(M1310) Pressure Ulcer Length Longest length head-to-toe
NA - No observable pressure ulcer(cm)
(M1322) Current Number of Stage I Pressure Ulcers Intact skin withnon-blanchable redness of a localized area usually over a bonyprominence The area may be painful firm soft warmer or cooler ascompared to adjacent tissue
(M1312) Pressure Ulcer Width Width of the same pressure ulcergreatest width perpendicular to the length
0 1 4 or more2 3(M1314) Pressure Ulcer Depth Depth of the same pressure ulcer fromvisible surface to the deepest area
Page 7 of 20
(cm)
(cm)
c Stage IV Full thickness tissue loss with visible bone tendonor muscle Slough or eschar may be present on some parts ofthe wound bed Often includes undermining and tunneling
d2 Unstageable Known or likely but unstageable due to coverageof wound bed by slough andor eschar
d3 Unstageable Suspected deep tissue injury in evolution
Patient Name Med Record
wwwpnsystemcom 3058185940 The Outcome and Assessment Information Set (OASIS) is the intellectual property of the Center for Health Services and Policy Research Denver Colorado It is used with permission Expiration date 7312012
Number Currently PresentNumber of those listed in COLUMN 1 that where
present on admission (most recent SOCROC)
Wound Measurement must be performed at least every week following thewound measuring guide or more often if ordered by the physicianAll results must be reflected in the Progress Note or Wound Record Summary (weekly)according your Policy Manual The revised WOCN Definitions and Guidance for OASIS-Ccan be reviewed at wwwwocnorgpdfsGuidanceOASIS-Cpdf Pressure soresWounds areeasy to develop but very difficult to cure Daily nursing care plays a large part in prevention Summary Procedure for Treatment Explain procedure to patient Screen patient wash area withsoap and water Apply special washing solution if ordered Massage the surrounding area brisklyaway from the pressure sore Massage reddened area slightly Apply medication if orderedRelieve the source of pressure according to what the doctor ordered (air mattress etc)Leave patient comfortable Wash hands
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INTEGUMENTARY STATUS (Contd)(M1324) Stage of Most Problematic Unhealed (Observable)Pressure Ulcer
1 -Stage I2 -Stage II3 -Stage III4 -Stage IV
NA - No observable pressure ulcer or unhealed pressure ulcer
(M1330) Does this patient have a Stasis Ulcer0 - No [Go to M1340]1 - Yes patient has BOTH observable and unobservable stasis ulcers2 - Yes patient has observable stasis ulcers ONLY3 - Yes patient has unobservable stasis ulcers ONLY (known but not
observable due to non-removable dressing) [Go to M1340]
(M1332) Current Number of (Observable) Stasis Ulcer(s)1 -One2 - Two3 - Three
4 - Four or more
(M1334) Status of Most Problematic (Observable) Stasis Ulcer 0 - Newly epithelialized
1 - Fully granulating 2 - Earlypartial granulation 3 - Not healing
(M1340) Does this patient have a Surgical Wound0 - No [Go to M1350]
1 - Yes patient has at least one (observable) surgical wound2 - Surgical wound known but not observable due to non-removable
dressing [Go to M1350]
(M1342) Status of Most Problematic (Observable) Surgical Wound0 - Newly epithelialized1 - Fully granulating2 - Earlypartial granulation3 - Not healing
(M1350) Does this patient have a Skin Lesion or Open Woundexcluding bowel ostomy other than those described above that isreceiving intervention by the home health agency
0 - No1 - Yes
WOUND CARE PROCEDURE (Check all that apply)
DIABETIC FOOT EXAM (mark all that apply)Wound care done during this visit Yes NoFrequency of diabetic foot examLocation(s) wound site
Patient
Done byCaregiver (name)Other
Soiled dressing removed by (use biohazard waste box)
RNPT
Patient
Yes No
Caregiver (name)
Exam by RNPT this visit
RNPT
Other
Significant integument findings
CleanTechnique used
Absent right left
Sterile
Pedal pulses Present right left
Wound cleaned with (specify)
Observation
Wound irrigated with (specify)
Lack of sense of Warm right left Cold right left
Wound packed with (specify)
Observation
Wound dressingcover applied (specify)
Neuropathy right left
Yes No
Left for
Procedure tolerated well
Right forAscending calf cm
Comments
Burning right leftTingling right left
Absent right leftPresent right leftLeg hair
Page 8 of 20
Patient Name Med Record
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1
2
3
4
Procedure
Yes NoWound left open to the air
Yes NoIs patient Diabetic
Daily Twice a day
Every other day Twice a week Weekly
Other
(please circle) (please circle)
(please circle) (please circle)
cm
(please circle)
(please circle)
(please circle)
(please circle)
(please circle)
Pressure ulcer ASSESSMENT (mark all that apply)
cm widthcm length1 Size cm depth
Location Shape Oval Round Other
Exudate Serous Serosanguineous SanguineousYes Nocm widthcm length2 Size cm depth
Location Shape Oval Round Other
Exudate Serous Serosanguineous SanguineousYes No
Authorization to takePhoto obtained
Yes No
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INTEGUMENTARY STATUS (Contd)(M1324) Stage of Most Problematic Unhealed (Observable)Pressure Ulcer
1 -Stage I2 -Stage II3 -Stage III4 -Stage IV
NA - No observable pressure ulcer or unhealed pressure ulcer
(M1330) Does this patient have a Stasis Ulcer0 - No [Go to M1340]1 - Yes patient has BOTH observable and unobservable stasis ulcers2 - Yes patient has observable stasis ulcers ONLY3 - Yes patient has unobservable stasis ulcers ONLY (known but not
observable due to non-removable dressing) [Go to M1340]
(M1332) Current Number of (Observable) Stasis Ulcer(s)1 -One2 - Two3 - Three
4 - Four or more
(M1334) Status of Most Problematic (Observable) Stasis Ulcer 0 - Newly epithelialized
1 - Fully granulating 2 - Earlypartial granulation 3 - Not healing
(M1340) Does this patient have a Surgical Wound0 - No [Go to M1350]
1 - Yes patient has at least one (observable) surgical wound2 - Surgical wound known but not observable due to non-removable
dressing [Go to M1350]
(M1342) Status of Most Problematic (Observable) Surgical Wound0 - Newly epithelialized1 - Fully granulating2 - Earlypartial granulation3 - Not healing
(M1350) Does this patient have a Skin Lesion or Open Woundexcluding bowel ostomy other than those described above that isreceiving intervention by the home health agency
0 - No1 - Yes
WOUND CARE PROCEDURE (Check all that apply)
DIABETIC FOOT EXAM (mark all that apply)Wound care done during this visit Yes NoFrequency of diabetic foot examLocation(s) wound site
Patient
Done byCaregiver (name)Other
Soiled dressing removed by (use biohazard waste box)
RNPT
Patient
Yes No
Caregiver (name)
Exam by RNPT this visit
RNPT
Other
Significant integument findings
CleanTechnique used
Absent right left
Sterile
Pedal pulses Present right left
Wound cleaned with (specify)
Observation
Wound irrigated with (specify)
Lack of sense of Warm right left Cold right left
Wound packed with (specify)
Observation
Wound dressingcover applied (specify)
Neuropathy right left
Yes No
Left for
Procedure tolerated well
Right forAscending calf cm
Comments
Burning right leftTingling right left
Absent right leftPresent right leftLeg hair
Page 8 of 20
Patient Name Med Record
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1
2
3
4
Procedure
Yes NoWound left open to the air
Yes NoIs patient Diabetic
Daily Twice a day
Every other day Twice a week Weekly
Other
(please circle) (please circle)
(please circle) (please circle)
cm
(please circle)
(please circle)
(please circle)
(please circle)
(please circle)
Pressure ulcer ASSESSMENT (mark all that apply)
cm widthcm length1 Size cm depth
Location Shape Oval Round Other
Exudate Serous Serosanguineous SanguineousYes Nocm widthcm length2 Size cm depth
Location Shape Oval Round Other
Exudate Serous Serosanguineous SanguineousYes No
Authorization to takePhoto obtained
Yes No
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WOUNDLESION Diagram41 2 3ULCER (specify)
Location (specify in diagram)
Type Pressure ulcerAbrasion
Venous stasis ulcer
Arterial Surgical
MechanicalFistulaMalignancy Incision
Diabetic foot ulcer
Size(cm) (LengthxWidthxDepth)
TunnelingUndermining (cm)Stage (I-II-III-IV)(pressure uIcers only)
Odor
Surrounding Skin
Edema (pedal sacral pitting etc)
DrainageAmountNoneSmall
ModerateLarge
NoneSmallModerate
Large
Small None
SmallModerateLarge
ColorClearTanSerosanquineousOther
Clear Tan
ClearTanSerosanguineousOther
Thin Thin ThinThinConsistency ThickThick Thick
FULL SYSTEMS REVIEW
reported reportedHeight Weight actualactualReported weight changes by
GainLoss wkmoyrlb X
VITAL SIGNS (Todays visit)
CARDIOPULMONARY STATUS (Contd)
Blood Pressure Sittinglying R LStanding R L
Oral AxillaryTemperature Rectal TympanicPulse BrachialApical
Radial CarotidRest ActivityCheynes Stokes
Death rattleRespirations Apnea periods -secAccessory muscles used
CARDIOPULMONARY STATUSBreath Sounds Cracklesrales Wheezesrhonchi Diminished Absent
AnteriorPosterior
RightRight Upper
LeftRight Lower
MurmurHeart SoundsLeft UpperLast date checkedPacemaker DateLeft Lower
Type
Page 9 of 20
INTEGUMENTARY STATUS (Contd)
2
ClearTanSerosanguineousOther
Serosanguineous
Thick
Other
None
Moderate Large
Patient Name Med Record
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(Fool normal etc)
(redness damage specify)
Stoma (Specify)
Is there at least one pressure ulcer that cannot be observed due to the presence of scar or a nonremovable dressing including casts
Yes No
Appearance ofthe Wound Bed
Treatment Ordered
Patient CaregiverFamily Nurse
Regular Irregular
SOBSOBOE
Regular Irregular
Clear
SOB on minimal effortwalk Ft
Regular Irregular
Chest Pain Anginal Postural Localized Substernal
Vise-like
Radiating to
Dull Ache Sharp
Associated with Shortness of breathSOBOE SweatsActivityFrequencydurationHow relieved
PalpitationsArrhythmias FatigueEdema Pedal Right Left Sacral
DependentNon-pittingPitting +1+2+3+4
SiteClaudicationCramps (site)
Capillary refill less than 3 sec greater than 3 secDisease Management Problems (explain)
Yes No
MedicationRestOther
Fastaccelerated Slow
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CARDIOPULMONARY STATUS (Contd) GENITOURINARY STATUS (Contd)
Other Problem (specify)
(M1600) Has this patient been treated for a Urinary Tract Infection inthe past 14 days
0 - No1 -Yes
NA - Patient on prophylactic treatmentUK - Unknown
(M1610) Urinary Incontinence or Urinary Catheter Presence
0 - No incontinence or catheter (includes anuria or ostomy for urinarydrainage) [Go to M1620]
1 - Patient is incontinent2 - Patient requires a urinary catheter (ie external indwelling
intermittent suprapubic) [Go to M1620]
(M1615) When does Urinary Incontinence occur0 - Timed-voiding defers incontinence1 - Occasional stress incontinence2 - During the night only
3 - During the day only 4 - During the day and night
(M1400) When is the patient dyspneic or noticeably Short of Breath0 - Patient is not short of breath
NUTRITIONAL STATUS
1 - When walking more than 20 feet climbing stairs 2 - With moderate exertion (eg while dressing using commode or
bedpan walking distances less than 20 feet)
NAS NPO
Controlled Carbohydrate
3 - With minimal exertion (eg while eating talking performing otherADLs) or with agitation
4 - At rest (during day or night)
amtRestrict fluids
Todays visit assessed Reported by
AnorexicPoor
(M1410) Respiratory Treatments utilized at home (Mark all that apply)
1 - Oxygen (intermittent or continuous)
AmountFrequency
2 - Ventilator (continually or at night)
Heartburn (food intolerance)
3 - ContinuousBi-level positive airway pressure
Other
4 - None of the above
GENITOURINARY STATUS Directions Circle each area with yes to assessment then total scoreto determine NUTRITIONAL RISK(Check all that apply)
2 Eats fewer than 2 meals per day 3Eats few fruits vegetables or milk products 2Has 3 or more drinks of beer liquor or wine almost every day 2Has tooth or mouth problems that make it hard to eat 2Does not always have enough money to buy the food needed 4Eats alone most of the time 1Takes 3 or more different prescribed or over-the-counter drugs a day 1Without wanting to has lost or gained 10 pounds in the last 6 months 2Not always physically able to shop cook andor feed self 2
TOTAL
Nocturia x
Urgencyfrequency
Burningpain Hesitancy
Hematuria Oliguriaanuria
Incontinence
Diapersother
Blood-tingedColor Yellowstraw Amber Browngray
Other
Clarity Clear Cloudy Sedimentmucous
Odor Yes NoReprinted with permission by the Nutrition Screening Initiative a project of the American Academy ofFamily Physicians the American Dietetic Association and the National Council on the Aging Inc andfunded in part by a grant from Ross Products Division Abbott Laboratories Inc
INTERPRETATION GUIDE
Urinary Catheter Type Last changed on
Foley inserted (date) with FrenchInflated balloon with mL without difficulty Suprapubic 0-2 Good Recommend Recheck hisher nutritional score in six months
3-5 Moderate risk See what can be done to improve the eating habits and lifestyleEducate refer monitor and reevaluate based on patient situation and Agency policyRecheck your nutritional score in three months
Irrigation solution Type (specify)
Amount mL Frequency Returns6 or more High risk Coordinate with physician dietitian social services or nurse
about how to boost the patient nutritional health Reassess nutritional statusand educate based on plan of care to improve hisher nutritional status
Patient tolerated procedure well Yes No
Urostomy (describe skin around stoma)
Describe at risk intervention and plan
Page 10 of 20
No Problem
DIET Nutritional requirements
Increase fluids amtAppetite Good Fair
Nausea Vomiting
Has an illness or condition that changed the kind andor amount offood eaten
Patient Name Med Record
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QA
Patient CaregiverFamily
LPM via cannula mask trach 02 saturationO2
Trach sizetype
CaregiverfamilyOtherSN
PatientWho manages
Intermittent treatmentsSAN (CampDB medicated inhalation treatments etc)N o
Yes explain
Cough N oNon-productiveProductive sputum colorYes
DescribeDuring ADLs effortDyspnea Rest
Comments
Positioning necessary for improved breathing SOB SOBOEN oYes describe
SleepingLyingOrthopnea
UrostomyFoley care managed by Patient CaregiverFamily
Urinary Bowel
SN
QA
No Problem
2 gm Sodium 1800 cal ADA
Low Fat Low cholesterol Other
16
Low Sodium
YES
Frequency
Excellent
(SOC)
Fire SafetyPrevention Plan explained SG
afternoonWorse at morning sleeping timeevening
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GENITALIA
No Problem
DischargeDrainage (describe)
Lesions Blisters Masses Cysts Wart
Inflammation Surgical alteration
Prostate problem BPH TURP Date
Self-testicular exam Frequency
Menopause Hysterectomy Date Date last PAP Results
Breast self-exam frequency Discharge RLMastectomy R L Date Other (specify)
(M1700) Cognitive Functioning Patients current (day of assessment)level of alertness orientation comprehension concentration andimmediate memory for simple commands
No Problem
0 - Alertoriented able to focus and shift attention comprehends andrecalls task directions independently
Flatulence
Diarrhea (Frequency)
Constipationimpaction
Hemorrhoids
Last BM
Rectal bleeding1 - Requires prompting (cuing repetition reminders) only under
stressful or unfamiliar conditions
Frequency of stools
Bowel regimeprogram2 - Requires assistance and some direction in specific situations (eg
on all tasks involving shifting of attention) or consistently requireslow stimulus environment due to distractibilityWeeklyLaxativeEnema use Daily Monthly
Other
Diapersother
Ileostomycolostomy site (describe skin around stoma)
No Problem
EliminationOstomy managed by PatientHeadache Location Frequency
OtherAphasia Receptive Expressive
Motor change Fine Gross Site
(M1620) Bowel Incontinence
Dominant side R L (circle)
0 -Very rarely or never has bowel incontinence
Weakness UE LE Location
1 - Less than once weekly
Tremors Fine Gross Paralysis Site
2 - One to three times weekly
Stuporous Hallucinations Visual Auditory (circle)
3 - Four to six times weekly
Hand grips Equal Unequal (specify)
4 - On a daily basis
Strong Weak (specify)Psychotropic drug use (specify)DoseFrequencyOther (specify)
(M1630) Ostomy for Bowel Elimination Does this patient have anostomy for bowel elimination that (within the last 14 days) a) was relatedto an inpatient facility stay or b) necessitated a change in medical ortreatment regimen
(M1710) When Confused (Reported or Observed Within the Last 14 Days)
0 - Patient does not have an ostomy for bowel elimination
0 - Never
1 - Patients ostomy was not related to an inpatient stay and did notnecessitate change in medical or treatment regimen
1 - In new or complex situations only
2 -The ostomy was related to an inpatient stay or did necessitate
2 -On awakening or at night only
change in medical or treatment regimen
3 - During the day and evening but not constantly4 - Constantly
ABDOMEN NA - Patient nonresponsive
No Problem
(M1720) When Anxious (Reported or Observed Within the Last 14 Days)Tenderness Distention Hard Soft AscitesPain (Frequency)
Abdominal girth cm 0 - None of the timeOther 1 - Less often than dailyBowel sounds active absent hypo hyperactive x quadrants 2 - Daily but not constantly
Other3 - All of the time
NA - Patient nonresponsive
Page 11 of 20
NEURO EMOTIONAL BEHAVIOR STATUS
ELIMINATION STATUS
3 - Requires considerable assistance in routine situations Is not alertand oriented or is unable to shift attention and recall directionsmore than half the time
4 - Totally dependent due to disturbances such as constantdisorientation coma persistent vegetative state or delirium
PERRLA Unequal pupils R L (circle)
5 - More often than once dailyNA - Patient has ostomy for bowel eliminationUK - Unknown
Patient Name Med Record
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NA No Problem
Nasogastric Gastrostomy JejunostomyOther (specify)
Pump (typespecify)Bolus Continuous
Feedings Type (amtrate)Flush Protocol (amtspecify)
SN OtherPerformed by Patient Caregiver
DressingSite care (specify)
Interventions instructionsComments
ENTERAL FEEDINGS - ACCESS DEVICE
Incontinence Urinary Bowel
CaregiverFamily SN
TPNDevice
IV
Following UniversalStandard precautions
Following UniversalStandard precautions
Other (specify)
Migraine Frequency
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NEURO EMOTIONAL BEHAVIOR STATUS (Contd)(M1730) Depression Screening Has the patient been screened for depression using a standardized depression screening tool
0 - No1 - Yes patient was screened using the PHQ-2 scale (instructions for this two-question tool Ask patient Over the last two weeks how often
have you been bothered by any of the following problems)
PHQ-2copy Not at All0-1 Day
Several Days2-6 Days
More Than Halfof the Days7-11 Days
Nearly Every Day12-14 Days
NAUnable toRespond
a) Little interest or pleasure in doing things 0 1 2 3 na
b) Feeling down depressed or hopeless 0 1 2 3 na
2 - Yes with a different standardized assessment and the patient meets criteria for further evaluation for depression3 - Yes patient was screened with a different standardized assessment and the patient does not meet criteria for further evaluation for depression
Copyright Pfizer Inc All rights reserved Reproduced with permission
(M1745) Frequency of Disruptive Behavior Symptoms (Reported orObserved) Any physical verbal or other disruptivedangerous symptomsthat are injurious to self or others or jeopardize personal safety
(M1740) Cognitive behavioral and psychiatric symptoms that aredemonstrated at least once a week (Reported or Observed)
(Mark all that apply)1 - Memory deficit failure to recognize familiar personsplaces 0 - Never
inability to recall events of past 24 hours significant memory lossso that supervision is required 1 - Less than once a month
2 - Once a month2 - Impaired decision -making failure to perform usual ADLs or IADLs 3 - Several times eachinability to appropriately stop activities jeopardizes safety through
actions3 -Verbal disruption yelling threatening excessive profanity
references etc4 - Physical aggression aggressive or combative to self and others
(eg hits self throws objects punches dangerouswith wheelchair or other objects)
5 - Disruptive infantile or socially inappropriate behavior (excludesverbal actions)
6 - Delusional hallucinatory or paranoid behavior7 - None of the above behaviors demonstrated
IMENTAL STATUS Inability to cope with altered health statusillness as evidenced by
1 - Oriented 5 - DisorientedLack of motivation
2 - Comatose Unrealistic expectations3 - Forgetful
Inability to recognize problems 4 - Depressed Denial of problems
ActualPotentialEvidence of abuse neglect exploitationVerbalEmotionalPsychologicalIntervention
FinancialPhysical
PSYCHOSOCIALSENSORY STATUS Describe
Comments
MUSCULOSKELETAL STATUS
Primary language
Learning barrier Mental Psychological Physical Functional Sensory
Unable to readwrite Higher Educational Level
Spiritual CulturalEthnicReligion implications that impact care
No Problem
Explain
Fracture (location)
Swollen painful joints (specify)
Spiritual resourceContractures JointLocation
Phone No Assistive DeviceAtrophySleepRest Adequate Inadequate
Decreased ROM ParesthesiaExplainShuffling Wide-based gait Weakness
Amputation BKAKUE RL (specify)Inappropriate responses to caregiversphysicianclinician staffInappropriate follow-through in pastAngry
ParaplegiaFlat affect
Hemiplegia QuadriplegiaDiscouraged
Other (specify)Withdrawn Difficulty coping DisorganizedDepressed RecentLong term
Treatment
Page 12 of 20
4 - Several times a week 5 - At least daily
(M1750) Is this patient receiving Psychiatric Nursing Services at homeprovided by a qualified psychiatric nurse
0 - No1 - Yes
MENTAL STATUS
6 - Lethargic7 - Agitated
8 - Other
Language barrier Needs interpreter
Patient Name Med Record
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19
Forgetful at times Irritable Anxious Alert
No Problem
English SpanishOther
Deaf Needs American Sing language interpreter
Anxiety RecentLong termTreatment
No Problem
Creole Russian
Sometimes Inadequate
Not hope in recovery
Refuse to follow MD orders
Abandon
PSYCHOLOGICAL STATUS (Contd)
No Problem
Orthopedic cast Removable Permanent for days
Unsteady Gait Transfer ProblemsWheelchair Cane
Walker Other
Orthopedic Protesys Knee Replacement L R Other
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FUNCTIONAL LIMITATIONS ADLIADLs
(M1800) Grooming Current ability to tend safely to personal hygiene7-Ambulationneeds (ie washing face and hands hair care shaving or make up
1 -Amputation
teeth or denture care fingernail care) 2-BowelBladder 8-Speech
0 - Able to groom self unaided with or without the use of assistive(incontinence)
9-Legally blinddevices or adapted methods
3 - Contracture
A -Dyspnea with
1 - Grooming utensils must be placed within reach before able to
4-Hearing
complete grooming activities
B- Other (specify)
5-Paralysis
2 - Someone must assist the patient to groom self
6-Endurance
3 - Patient depends entirely upon someone else for grooming needs
(M1810) Current Ability to Dress Upper Body safely (with or withoutdressing aids) including undergarments pullovers front-opening shirtsand blouses managing zippers buttons and snaps
FALL RISK ASSESSMENT 0 - Able to get clothes out of closets and drawers put them on and
remove them from the upper body without assistance1 - Able to dress upper body without assistance if clothing is laid out
or handed to the patient2 - Someone must help the patient put on upper body clothing3 - Patient depends entirely upon another person to dress the upper
body
(M1830) Bathing Current ability to wash entire body safely Excludes grooming (washing face washing hands and shampooing hair)
1 - With the use of devices is able to bathe self in shower or tubindependently including getting in and out of the tubshower
2 - Able to bathe in shower or tub with the intermittent assistance ofanother person(a) for intermittent supervision or encouragement or reminders
OR(b) to get in and out of the shower or tub OR(c) for washing difficult to reach areas
3 - Able to participate in bathing self in shower or tub but requirespresence of another person throughout the bath for assistance orsupervision
4 - Unable to use the shower or tub but able to bathe selfindependently with or without the use of devices at the sink inchair or on commode
5 - Unable to use the shower or tub but able to participate in bathing
(M1910) Has this patient had a multi-factor Fall Risk Assessment (suchas falls history use of multiple medications mental impairment toiletingfrequency general mobilitytransferring impairment environmentalhazards)
self in bed at the sink in bedside chair or on commode with theassistance or supervision of another person throughout the bath
6 - Unable to participate effectively in bathing and is bathed totally byanother person
0 - No multi-factor falls risk assessment conducted
(M1840) Toilet Transferring Current ability to get to and from the toiletor bedside commode safely and transfer on and off toiletcommode
1 - Yes and it does not indicate a risk for falls2 - Yes and it indicates a risk for falls
0 -Able to get to and from the toilet and transfer independently withor without a device
PlanComments
1 -When reminded assisted or supervised by another person ableto get to and from the toilet and transfer
2 - Unable to get to and from the toilet but is able to use a bedsidecommode (with or without assistance)
3 - Unable to get to and from the toilet or bedside commode but isable to use a bedpanurinal independently
4 - Is totally dependent in toileting
Page 13 of 20
(M1820) Current Ability to Dress Lower Body safely (with or without)dressing aids) including undergarments stacks socks or nylons shoes 0 - Able to obtain put on and remove clothing and shoes without
assistance 1 - Able to dress lower body without assistance if clothing and shoes
are laid out or handed to the patient
2 - Someone must help the patient put on undergarments slackssocks or nylons and shoes
3 - Patient depends entirely upon another person to dress lower body
0 - Able to bathe self in shower or tub independently includinggetting in and our of tubshower
Patient Name Med Record
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18A
Dizziness
Generalized WeaknessArthralgia
InsomniaHeadache
AnxietySOB on exertion
Heartburn
Poor vision
Productive cough
Unsteady GaitPain on ambulation
Varicositis on lower extEdema in __________
Legs weak
Chest pain on exertionFatigues at times
Decreased Bil breath soundsBack Pain
PalpitationsLimited MobilityLimited ROMLeg crampsFreq Coughing episodesNeeds assistance of 1 person
Implement fall precautions for a total score of 10 or greater
Patient Factors Circle appropriate score for each section and total score at bottom (MedQIC) ScoreLevel of Consciousness Mental Status Disoriented X 3 at all times (M1700) 2Level of Consciousness Mental Status Intermittent confusion (M1700 - M1710) 4History of Falls (past 3 months) 1-2 falls (M1032) 2History of Falls (past 3 months) 3 or more falls (M1032) 4Ambulation Elimination Status Chair bound amp requires assist w toileting (M1840) 2Ambulation Elimination Status Ambulatory amp incontinent (M1610 - M1615) 4Vision Status Poor (w or wo glasses) (M1200) 2Vision Status Poor (Legally blind) (M1200)Gait and Balance (Balance problem while standing)Gait and Balance (Balance problem while walking) 1
Gait and Balance (Decreased muscular coordination)
Gait and Balance (Change in gait pattern when walking through doorway) 1Gait and Balance (Jerking or unstable when making turns) 1Gait and Balance (Requires assistance (person furniturewalls or device))
Orthostatic Changes (Droplt20mmHg in BP between lying and standing Increase of cardiac rhythm lt20)
Orthostatic Changes (Drop gt20mmHg in BP between lying and standing Increase of cardiac rhythm gt20)
4
Predisposing Diseases (1-2 present)
Equipment Issues (Oxygen tubing) 1
Total points
4
1
1
2
Medications (Takes 1-2 of these medications currently or win past 7 days)
1
42
Medications (Takes 3-4 of these medications currently or win past 7 days)
Medications (Mark additional point if patient has had a change in these medications or doses in past 5 days) 1
2Predisposing Diseases (3 or more present) 4
Equipment Issues (Inappropriate or client does not consistently use assistive device)
Equipment Issues (Other ) 1
1Equipment Issues (Equipment needs ) 1
Established by the Centers for Medicare amp Medicaid Services (CMS) QualityNet provides healthcare quality improvement news resources and data reporting tools and applications used by healthcare providers and others
Additional service Needed-Impaired Mobility -History of Falls -Predisposing DX - Weakness --Knowledge Deficit or noncompliance with activity restrictions Physical Therapy
Order Obtained
-Unsafe Living Environment -Pt demo unsafe behavior or choices -Limited Resources -At risk and lives alone -Pt is CG for another
Medical Social Services
-ADLIADL Deficits -Sensory Deficits -Decreased Cognition-Unsafe living environment -UE limitations
Occupational Therapy
- - - - - - - -
- - - - - - - -
Certain abilities needed to function independently can be developed or maintained by managing symptoms or through physical or occupational therapy Home health staff needs to evaluate the need for any special assistance devices or equipment and trainpatients on their use If a patient can perform this activity with little assistance they are more independent self-confident and active
If no additional services requested check reasonDiscipline already ordered Pt has been assessed by this discipline win last 30 daysPatientFamily refused additional discipline
QA
(SOC)
SG
No other service approved by Patients Physician
SG
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ADLIADLs (Contd)(M1880) Current Ability to Plan and Prepare Light Meals (eg cerealsandwich) or reheat delivered meals safely
(M1845) Toileting Hygiene Current ability to maintain perineal hygienesafely adjust clothes andor incontinence pads before and after usingtoilet commode bedpan urinal If managing ostomy includes cleaningarea around stoma but not managing equipment
0 - (a) Able to independently plan and prepare all light meals for selfor reheat delivered meals OR
0 - Able to manage toileting hygiene and clothing management (b) Is physically cognitively and mentally able to prepare lightwithout assistance meals on a regular basis but has not routinely performed light
meal preparation in the past (ie prior to this home careadmission)1 - Able to manage toileting hygiene and clothing management
without assistance if suppliesimplements are laid out for the1 - Unable to prepare light meals on a regular basis due to physicalpatient
cognitive or mental limitations2 - Someone must help the patient to maintain toileting hygiene2 - Unable to prepare any light meals or reheat any delivered mealsandor adjust clothing
3 - Patient depends entirely upon another person to maintain toileting(M1890) Ability to Use Telephone Current ability to answer the phonesafely including dialing numbers and effectively using the telephone tocommunicate
hygiene
(M1850) Transferring Current ability to move safely from bed to chairor ability to turn and position self in bed if patient is bedfast 0 - Able to dial numbers and answer calls appropriately and as
desired0 - Able to independently transfer 1 - Able to use a specialty adapted telephone (ie large numbers on
the dial teletype phone for the deaf) and call essential numbers1 -Able to transfer with minimal human assistance or with use of anassistive device 2 - Able to answer the telephone and carry on a normal conversation
but has difficulty with placing calls2 -Able to bear weight and pivot during the transfer process butunable to transfer self 3 - Able to answer the telephone only some of the time or is able to
carry on only a limited conversation3 - Unable to transfer self and is unable to bear weight or pivot when4 - Unable to answer the telephone at all but can listen if assistedtransferred by another person
with equipment4 - Bedfast unable to transfer but is able to turn and position self in5 - Totally unable to use the telephonebed
NA - Patient does not have a telephone5 - Bedfast unable to transfer and is unable to turn and position self
RefusedIndications for Home Health Aide may be needed
(M1860) AmbulationLocomotion Current ability to walk safely oncein a standing position or use a wheelchair once in a seated position ona variety of surfaces
NoYesMD Order obtained
OTSN MSWOther Services ordered STPT
0 - Able to independently walk on even and uneven surfaces and
Comment
negotiate stairs with or without railings (ie needs no humanassistance or assistive device)
1 - With the use of a one-handed device (eg cane single crutchhemi-walker) able to independently walk on even and uneven sur-faces and negotiate stairs with or without railings
2 - Requires use of a two-handed device (eg walker or crutches) to(M1900) Prior Functioning ADLIADL Indicate the patients usualability with everyday activities prior to this current illness exacerbationor injury Check only one box in each row
walk alone on a level surface andor requires human supervisionor assistance to negotiate stairs or steps or uneven surfaces
3 - Able to walk only with the supervision or assistance of another
Functional Area IndependentNeeded
Some HelpDependent
a Self-Care (eg groomingdressing and bathing) 0 1 2
b Ambulation 0 1 2
c Transfer 0 1 2
d Household tasks (eglight meal preparationlaundry shopping)
0
1 2
person at all times
4 - Chairfast unable to ambulate but is able to wheel selfindependently
5 - Chairfast unable to ambulate and is unable to wheel self
6 - Bedfast unable to ambulate or be up in a chair
(M1870) Feeding or Eating Current ability to feed self meals andsnacks safely Note This refers only to the process of eating chewinqand swallowing not preparing the food to be eaten
0 - Able to independently feed self
ACTIVITIES PERMITTED
1 - Able to feed self independently but requires(a) meal set-up OR(b) intermittent assistance or supervision from another person OR(c) a liquid pureed or ground meat diet 8-Crutches1 -Complete bedrest
9-Cane2-BedrestBRP2 -Unable to feed self and must be assisted or supervisedA-Wheelchair3-Up as toleratedthroughout the mealsnackB-Walker4-Transfer bedchair3 - Able to take in nutrients orally and receives supplemental nutrientsC-No restrictions5-Exercises prescribedthrough a nasogastric tube or gastrostomy
D-Other (specify)6-Partial weight bearing4 - Unable to take in nutrients orally and is fed nutrients through anasogastric tube or gastrostomy
7-Independent in home5 - Unable to take in nutrients orally or by tube feeding
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Patient Name Med Record
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If the patient experiment-ADLIADL Deficit - Elimination Deficit - Impaired Mobility
18BCMS 485 (POC)
PatientFamily
NA (Home Health Aide Services not needed)
(SOC)
(M1910) See previous page 13 before the FALL RISK ASSESSMENT
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ALLERGIES MEDICATIONS(M2040) Prior Medication Management Indicate the patients usualability with managing oral and injectable medications prior to this currentillness exacerbation or injury Check only one box in each row
None known NKA AspirinSulfaPollens and mold spores
EggsPenicillin
Insect bitesDairyMilk products
Functional Area Independent NeededSome Help Dependent Not
Applicable
a Oralmedications 0 1 2 na
b Injectablemedications 0 1 2 na
Other
MEDICATIONS
(M2000) Drug Regimen Review Does a complete drug regimen reviewindicate potential clinically significant medication issues eg drugreactions ineffective drug therapy side effects drug interactionsduplicate therapy omissions dosage errors or noncompliance
0 - Not assessedreviewed [Go to M2010]
1 - No problems found during review [Go to M2010]
2 - Problems found during reviewNA - Patient is not taking any medications [Go to M2040]
INFUSION IV THERAPYNA
(M2002) Medication Follow-up Was a physician or the physician-designee contacted within one calendar day to resolve clinicallysignificant medication issues including reconciliation
Peripheral line Central line
Typebrand
0 - No
Size
1 -Yes
Non-tunneledGroshong Non-Groshong TunneledInsertion site Insertion date
(M2010) PatientCaregiver High Risk Drug Education Has the patientcaregiver received instruction on special precautions for all high-riskmedications (such as hypoglycemics anticoagulants etc) and how andwhen to report problems that may occur
Lumens DoubleSingle TripleFlush solution
YesPatent N o
0 - No
Injection cap change frequency
1 -Yes
Dressing change frequency
NA - Patient not taking any high risk drugs OR patientcaregiver fullyknowledgeable about special precautions associated with allhigh-risk medications
Sterile CleanPatient RNPerformed by Caregiver Other
Siteskin condition
(M2020) Management of Oral Medications Patients current ability toprepare and take all oral medications reliably and safely includingadministration of the correct dosage at the appropriate timesintervalsExcludes injectable and IV medications (NOTE This refers to abilitynot compliance or willingness)
External catheter lengthOtherComment
0 - Able to independently take the correct oral medication(s) and
PICC Specific
proper dosage(s) at the correct times
Circumference of arm
1 - Able to take medication(s) at the correct times if
X-ray verificationYes No
(a) individual dosages are prepared in advance by another personOR
IVAD Port Specific
(b) another person develops a drug diary or chart
Reservoir DoubleSingle
2 - Able to take medication(s) at the correct times if given reminders
Huber gaugelength
by another person at the appropriate times
NoAccessed Yes date
3 - Unable to take medication unless administered by another person
EpiduralIntrathecal Access
NA - No oral medications prescribed
Siteskin condition
(M2030) Management of Injectable Medications Patients currentability to prepare and take all prescribed injectable medications reliablyand safely including administration of correct dosage at the appropriatetimesintervals Excludes IV medications
Infusion solution (typevolumerate)DressingOtherComment
0 - Able to independently take the correct medication(s) and properdosage(s) at the correct times
1 - Able to take injectable medication(s) at the correct times if
IV-Infusion Medication(s) administered
(a) individual syringes are prepared in advance by another
Drug Name
person OR
RouteDose
(b) another person develops a drug diary or chart
Frequency Duration of therapy
2 - Able to take medication(s) at the correct times if given remindersby another person based on the frequency of the injection
IV-Infusion Medication(s) administered
3 - Unable to take injectable medication unless administered by
Drug Name
another person
Dose Route
NA - No injectable medications prescribed
Frequency Duration of therapy
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Patient Name Med Record
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Financial ability to pay for medications Yes No
Was MSW referral made Yes
CommentPlan
Infusion IV Therapy order obtained verified
Gauge Length
Frequency
Iodine
Medline catheter
No
- Unsafe Living Environment -Pt demo unsafe behavior or choices - Limited Resources -At risk and lives alone -Pt is CG for another Yes No
Intravenous IV Port Yes No Flush Ordered Yes NoLast flushed date(vascular access device)
IV Therapy complication observed Pain amp irritation Infiltration amp exravasionOcclusionobstruction fluid overload Other
Dust mitesAnimal dander and urine
(SOC)
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INFUSION IV THERAPY (Contd)
Infusion care provided during visitPump (type specify)OtherCaregiverPatient RNAdministered by
Purpose of Intravenous Access
Pain control
Lab drawsInterventions Instructions Comments Problems DetectedAntibiotic therapy
Maintain venous accessChemotherapyParenteral nutrition (TPN)HydrationOther
CARE MANAGEMENT
(M2100) Types and Sources of Assistance Determine the level of caregiver ability and willingness to provide assistance for the following activitiesif assistance is needed (Check only one box in each row)
Caregiver(s)Caregiver(s) Unclear ifNeed TrainingCaregiver(s) AssistanceNo Assistance Not Likely toCurrently Supportive Caregiver(s) Needed ButType of Assistance Needed in This Provide ProvideServices to Will Provide No Caregiver(s)Area Assistance AssistanceAssistance Provide Available
Assistance
a ADL Assistance (egtransferambulation bathingdressing toileting eatingfeeding)
0 1 2 3 4 5
b IADL Assistance (egmeals housekeepinglaundry telephone shoppingfinances)
0 1 2 3 4 5
c Medication Administration(eg oral inhaled orinjectable)
0 1 2 3 4 5
d Medical ProceduresTreatments (eg changingwound dressing)
0 1 2 3 4 5
e Management of Equipment(includes oxygen IVinfusionequipment enteralparenteralnutrition ventilator therapyequipment or supplies)
0 1 2 3 4 5
f Supervision and Safety(eg due to cognitiveimpairment)
0 1 2 3 4 5
g Advocacy or Facilitation ofpatients participation inappropriate medical care(includes transportation to orfrom appointments)
0 1 2 3 4 5
(M2110) How Often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)1 - At least daily 4 - Received but less than weekly
5 - No assistance received2 - Three or more times per weekUK - Unknown3 - One to two times per week
APPLIANCES SPECIAL EQUIPMENT HOME MEDICAL EQUIPMENT Co
Needs (specify)BraceOrthotics (specify)
Bedside commodeTransfer equipment BoardLift Oxygen HME Co
Prosthesis RUE RLE LUELLEOther HME Rep
Grab bars BathroomOther
PhoneOrganizations providing Home Medical Equipment (HME)
Hospital bed Semi-elec Crank SpecLifeline
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Patient Name Med Record
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Ostomy Pliers Shower chair Scooters Hoists
Wheeled Walker Other Phone NA
NA
Removing line date (if know)
Expand intravascular volume
Blood and its derivativesNA
NA
NA
(SOC)
SGFire PreventionSafety Program in place Patient instructed
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SAFETY MEASURES LIVING ARRANGEMENTS SUPPORTIVE ASSISTANCE
Oxygen use NYSigns postedYFollow smoking flammables safety precautions N
Oxygen back-up Knows Instructed how to useAvailable
Oxygen Precautions explained
PlanComments
Safety hazards in the home (check all that apply)NYFire alarmsmoke detector Fire extinguish
Inadequate heating cooling electricity lightingHurricane Disaster Emergency supplieskits
NY
InstructionsInformation Provided Sign Up package (Check all that apply)
Y N
Patient Rights and responsibilities
NYFirst aid boxEmergency Equipment or Supplies
State hotlineABUSE number
NYUnsafe gaselectrical appliances or electrical outlets
Advance directives information
NYInadequate running water plumbing problemsDo not resuscitate (DNR) (if applicable)NUnsafe storage of supplies equipment HME
No telephone available andor unable to use the phonePest problems InsectsrodentsMedications stored safely clearly-easy use check interactions
Service AgreementContractNYOASISHIPAA Privacy Notice ConfidentialityNY
Emergency Plan classification instructionsNYAgency phone numbers addressEmergency planning Exit Plan in place more than one exitClient Information Handbook
Y N
Standard precautions handwashing Infection Control
NYEnough Ventilation
Home safety guidelines
Safe BedsChairs clear pathways
Admission criteria Information for Home visit Services FrequencyY NAble to follow directions in case of Emergency
Diabetes Control other disease management informationNYSlippery Floors Ashtrays (if a smoker)
Fall Prevention Program
NYPlan for power failure emergency lights flashlights etc
THERAPY AND PLAN OF CARE(M2200) Therapy Need in the home health plan of care for the Medicarepayment episode for which this assessment will define a case mixgroup what is the indicated need for therapy visits (total of reasonableand necessary physical occupational and speech-language pathologyvisits combined) (Enter zero [000] if no therapy visits indicated)
) Number of therapy visits indicated (total of physicaloccupational and speech-language pathology combined)
(
NA - Not applicable No case mix group defined by this assessment(M2250) Plan of Care Synopsis (Check only one box in each row) Does the physician-ordered plan of care include the following
PlanIntervention YesNo Not Applicable
a Patient-specific parameters for notifying physician ofchanges in vital signs or other clinical findings 0 1 na
Physician has chosen not to establish patient-specific parameters for this patient Agency will usestandardized clinical guidelines accessible for allcare providers to reference
b Diabetic foot care including monitoring for the presence ofskin lesions on the lower extremities and patientcaregivereducation on proper foot care
0 1 naPatient is not diabetic or is bilateral amputee
c Falls prevention interventions 0 1 na Patient is not assessed to be at risk for falls
d Depression intervention(s) such as medication referral forother treatment or a monitoring plan for current treatment 0 1 na Patient has no diagnosis or symptoms of
depression
e Intervention(s) to monitor and mitigate pain 0 1 na No pain identified
f Intervention(s) to prevent pressure ulcers 0 1 na Patient is not assessed to be at risk for pressureulcers
g Pressure ulcer treatment based on principles of moistwound healing OR order for treatment based on moistwound healing has been requested from physician
0 1 naPatient has no pressure ulcers with need for moistwound healing
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Y
NY
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Patient Name Med Record
HOME ENVIRONMENT SAFETY
NYRelevant medical appliances if applicable ( wheelchair O2 Monitors etc)NYHurricane Shutter Disaster Plan
Medication sheet reconciliatedchecked
Alzheimers Sensory impairments info
Care Plans
Pain Management info Grievance Procedures
Local Resources Guide Mission ownership information
Physical Therapy Total visitsOccupational Therapy Total visits
Speech Therapy Total visitsOther Therapy Total visits
(SOC)
Safety Measures CMS485 (POC)
Cast PrecautionsChange position slowlyCoumadinHeparin PrecautionsDo not lift bend stoopGood handwashing techniqueOxygen PrecautionFire preventionPractice Universal Precautions
15
Safe Ambulation
Respiratory PrecautionsDiabetic PrecautionsWoundDecubitus precautionsAdequate lightingPrevent Cardiac OverloadPrevent Falls and Injuries GI Precautions
Prev Infection ComplicationsSeizure PrecautionsSuicide precautionsSupport due functional limitationTeach coping skillsSafe storagedisposal syringes Cardiac Precautions
GU Precautions
Safe TransfersSAN PrecautionsCatheter CareProvide Emotional SupportEmergency Plan
Maintain Safeclear EnvironmentMaintain Good Skin care
Clear pathways
Other
SG
Correct handwashing technique SG
Check bathroom floorstairs for safety hazardsPsycho-social behavior precautions
SG
SGSG
SG
SG
SG
Other
SG
SG
SG
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PATIENT CARE COORDINATION
CARE PLAN Reviewed with patient involvementOrder obtainedMedication Form completedreviewedupdated No changeMEDICATION RECORD
Ineffective drug therapySignificant drug interactions
Significant side effectsNon-compliance with drug orders Duplicate drug therapy
Other (specify)M S WSNPhysician AidePT OT STCARE COORDINATION
Explain
Yes No
DME SUPPLIES
IV start kit Underpads size BathbenchChemstrips2x2sIV pole
External catheters
Syringes Cane Quad CaneIV tubing
Urinary bagpouch
COTTON TIP APP4x4s
CommodeAlcohol swabs
Ostomy pouch (brand size)
Special mattress overlayABDs
Angiocatheter size
Cotton tipped applicatorsPeroxide Ostomy wafer (brand size)
Pressure relieving device
Wound cleanserExtension tubingsWound gel
Injection caps
Stoma adhesive tape
Eggcrate
Drain sponges Central line dressing
Skin protectant
Hospital bed
GlovesNon-sterile
Side Rails
Infusion pump Hoyer lift
Sterile Batteries size Enteral feeding pump
Hydrocolloids
Enema suppliesSyringes size
Nebulizer
Kerlix size
Feeding tubeNu-gauze
MEFIX 2X11 YD (EA)
Oxygen concentrator
sizetype Suction machine
SalineNSS
FOLEYCATH SUPPLIES
Suture removal kit Ventilator
Tape
Fr catheter kit
Staple removal kit Walker
(tray bag foley)Transparent dressings
Steri strips
Straight catheter
Wheelchair
Ointment
TRIPLE ANTIBIOTIC 30GR
Irrigation tray
Tens unitSalineNSS
OtherAcetic acid
Other
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Patient Name Med Record
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10
14
PATIENTCAREGIVER INSTRUCTIONS-TEACHINGCheck all that appliesPatientcaregiver(CG) independent with
Trach care
N oYesWoundDecubitus care
Yes No
Yes N o
Ostomy care Yes
N oYesDiabetic managementcare
N o
N oYesNoYesInsulin administration N oYes
Oxygen useprecautions
Yes N oGlucometer usecalibration N oYes
Use of home medical equipmentdevices
N oYesNutritional managementDiet
NoCaregiver present during the visit Yes
PatientCG educationteaching this visit for
N oYesPatientCG able to understand instructionsteaching
Does the patientCG have a plan when disease symptoms exacerbate (eg when to call the nurseAgency vs emergency 911) N oYes
Comment(s)
SKILLED CARE PROVIDED THIS VISIT
Medication management Administration Oral Injection IV-Infused Inhaled
Foley care Yes N o
Pain ManagementHome prescribed exercisesActivities of Daily LivingPersonal Care
MEDICATION
DISEASE PROCESS COMPLICATIONSSS OFILEAL CONDUITOSTOMY SKINFOOT CAREDIET FLUIDS INFECTION CONTROL
OTHER INSTRUCTIONS GIVEN
N oYesElimination Incontinence management
NEEDS FURTHER TEACHINGExplain
NA NANANANANA
NANANANANANANA
Yes N oPhysician follow up visitsappointments NA
Expected Outcome
DISCHARGE PLANNING DISCUSSEDEXPLAINED Patient unable to perform own Wound Care dueto
Patient unable to InsulineInjection self administration dueto
No SO or CG ablewilling for wound careInsulin-Injection administration at this time
Telfa
Colostomy Supplies
Thermometer
Texas Cath
Red Box (Biohazard)
Betadine Solution
Abd Pads
Duoderm
Sharp Container
Ace band size
Leg Straps Cath
ALCOHOL PREP PADS
DUODERM CFGHY-TAPE 2INSERTION TRAY 5CC
INSULIN SYRINGE ____ CCSYRINGES
Glucometer
MICROPORE TAPE 2
SOFTWICK 4X4
VASELINE GAUZE 3X9
KLING 4
(SOC)
Medication Management Check all that appliesidentified Potential adverse effectsdrug reactionsSG
Skil led Observation AssessmentINJECTION ROUTE_______ SITE _____ MED GIVEN ______________________ DOSE __________ REACTION _____________________________
Foley ChangeCare Patient Educationteaching Wound Care Dressing Change Prep Admin Insulin
StandardUniversal Precautions Followed Aseptic Tech Used Quality Control of Glucometer Performed Sharps Discarded Inside Sharps Container
ProcedureTx welltolerated by Pt
Diabetic Observation Care
Correct handwashing technique followed SG ManagementEvaluation Patients Care Plan No caregiverfamily availablewilling to help patient with care procedures
SG
Pshycological carebehaviour problems prevention NA
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Orders by discipline (optional) To complete CMS485 (POC)
SN - ORDERS - FREQUENCYDURATION
Page 19 of 20
Patient Name Med Record
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21
OTHER
General
Psychiatric
F o l e y Care
REPORT ANY ELEVATIONS IN TEMPERATURE TO THE MD
Wound CareDecubitus
IMPROVE THE PTS ABILITY TO PREVENT OR COPE WITH BREATHING DIFFICULTIES
Asthma Respiratory
INST FOR SS EASY FATIGABILITY DYSPNEA PALPITATIONS ANGINA TACHYCARDIAPALLOR DIZZINESS JAUNDICE AND FEVER INST FOR G I DISTURBANCES ASSESS FOR CENTRALNERVOUS SYSTEM SYMPTOMATOLOGY OBTAIN APPROPRIATE LAB TESTS AND REPORT FINDINGS TO MD ADMINISTER PRESCRIBED INJECTABLE _________________ USING ______ TECHNIQUE
Anemia
Included as reference only your Professional Staff must reviewupdatepersonalizedapprove the orders
INSTRUCT IN PREPARATION amp ADMINISTRATION OF INSULIN INSTRUCT ONSET PEAK ampDURATION OF ACTION OF INSULIN INSTRUCT PROPER DISPOSAL OF SYRINGESNEEDLES NURSE TO MONITOR BLOOD SUGAR WITH GLUCOMETER OR ___________ON __________FREQUENCY ampNOTIFY MD OF ALTERED RESULTS TEACH GLUCOMETER OR __________ PROCEDURE amp INTERPRETING RESULTS
InsulinGlucometer
INST DISEASE PROCESS amp COMMON COMPLICATIONS INST PRESCRIBED DIET amp SHOPPING ADVICE INST SSHYPOHYPERGLYCEMIA amp EMERGENCY PROCEDURES INST GOOD SKIN CARE amp GOOD FOOT CARE DAILY CARE OFTEETH INST DIABETIC CHART INST SampA TESTING amp READING RESULTS INSTRUCT TO CARRY ID THAT INCLUDESINFORMATION REGARDING DIABETIC STATUS NAMES amp DOSAGE OF MEDS amp ACTION TO TAKE IF INSULIN REACTION OCCURS INST IMPORTANCE OF GOOD PERSONAL HEALTH HABITS INCLUDING EXERCISE ADEQUATEREST SLEEP REGULAR MED CHECK-UPS (INCLUDING PODIATRIC OPTHAMOLOGIST amp DENTIST)
DiabetesMellitus
INST PACED ACTIVITY PROGRAM
OBSERVE FOR SS OF DECOMPENSATION SUCH AS INCREASING TACHYCARDIA WSUDDEN ONSET SOB ON MINEXERTION ORTHOPNEA EXTREME ANXIETY PROGRESSIVE CYANOSIS GENERALIZED PALLOR AND DIAPHORESISCHF
INSTRUCT PROPER ADMINISTRATION OF OXYGEN THERAPY INSTRUCT OXYGEN PRECAUTIONSINSTRUCT MAINTENANCE OXYGEN EQUIPMENTOxygen
ASSESS FOR CHEST PAIN TYPE LOCATION INTENSITY DURATION amp FREQUENCY IS PAINMANAGEMENT NOTIFY MD IF PAIN PERSISTS IS GRADUAL PROGRESS ACTIVITY INCREASEINST DISCONTINUE ACTIVITY IF CHEST PAIN DYSPNEA FATIGUE OR PALPITATIONS OCCUR
Angina
PSYCHOLOGICAL ASSESSMENT ASSESS NEUROLOGICAL STATUS IMPLEMENT AND MONITOR BOWEL REGIMEN ampTEACH PROGRAM TO FAMILY SN TO MONITOR TRANQUILIZER EFFECTS GIVEN FOR SEVERE AGITATIONANXIETYEVALUATE FOR WEIGHT LOSS WEIGH PATIENT Q VISIT AND RECORDS WEIGHTS MONITOR LEVEL OFCONSCIOUSNESS ASSESS COORDINATION AND BALANCE PROVIDE EMOTIONAL SUPPORT TO PATIENT ANDFAMILY OBSERVATION AND EVALUATION OF BLADDER ELIMINATION HABITS MANAGEMENT IF INCONTINENCEASSIST FAMILY IN SETTING UP ROUTINE PATIENT-CENTERED AND STRESS THE IMPORTANCE OF ADHERING
Alzheimers
AIDE - ORDERS - FREQUENCYDURATIONTUBSHOWER BATH PERSONAL CARE HAIR COMB SHAMPOO PRN MOUTHDENTURE CARE SKIN CHECK ORAL HYGIENE TPRASSIST TO DRESS ASSIST WITH AMBULATION PREPARE SERVE MEALS GROCERY SHOP WASH CLOTHES LIGHT HOUSEKEEPING ASSIST WITH PERSONAL CARE AND ADLSERRANDS NOTIFY LAST BM IF NONE FOR 3 DAYS FEETNAILS CARE PERI CARE REPORT SIGNIFICANT FINDING TO SN STRAIGHTEN ROOM amp CHANGE LINEN
PT - ORDERS - FREQUENCYDURATIONEVALUATE BALANCE AND COORDINATION EVALUATE ENDURANCE MOBILITY NEUROMUSCULAR RE-EDUCATIONPERFORM PRESCRIBED THERAPEUTIC EXERCISES NOTIFY SIGNIFICANT FINDING TO MDAGENCY BED MOBILITY TRAININGGAIT TRAINING WITH ASSISTIVE DEVICE TEACH HOME MAINTENANCE PROGRAM AND STRENGTHENING EXERCISEEXERCISE BOTH PASSIVE AND ACTIVE EXERCISE REGIMEN TRANSFER TRAINING INSTRUCT IN SAFETY MEASURES FALL PRECAUTIONS
OT - ORDERS - FREQUENCYDURATIONEVALUATE PATIENT AND HOME FOR SAFETY ADL TRAINING PROGRAM MUSCLE RE-EDUCATION BODY IMAGE TRAININGINCREASE RIGHT AND LEFT UPPER EXTREMITIES STRENGTH THERAPEUTIC EXERCISE TO (R) AND (L) HANDINCREASE STRENGTH AND COORDINATION PROPRIOCEPTION AND SENSATION
ST FOR EVALUATION TO PROVIDE ORAL MOTOR EXERCISES INVOLVING LINGUAL AND LABIAL EXERCISES SPEECH ARTICULATION DISORDER TREATMENTIMPROVE SPEECH FACIAL SYMMETRY AND MUSCULATION IMPROVE DYSPHAGIA VOICE DISORDER TREATMENT AURAL REHABILITATION NON-ORAL COMMUNICATION LANGUAGE DISORDER TREATMENT
ST - ORDERS - FREQUENCYDURATION
MSW - ORDERS - FREQUENCYDURATIONMSW FOR ASSESSMENT OF SOCIAL AND EMOTIONAL FACTORS COMMUNITY RESOURCE PLANNINGCOUNSELING REGARDING MANAGEMENTADJUSTMENT TO ILLNESS LONG RANGE PLANNING AND DECISION MAKING
PROVIDE SUPPORTIVE AND RELAXATION THERAPY PROVIDE FAMILY THERAPY ASSESS INTERPERSONALBEHAVIOR ASSIST PATIENT TO DEFINE PROBLEMS amp SOCIAL RELATIONSHIPS GIVE POSITIVE REINFORCEMENTASSIST PATIENT TO VERBALIZE FEELINGS
Anxie ty
INST DISEASE PROCESS AND COMMON COMPLICATIONS INST LOW SODIUM DIET - STRESSING IMPORTANCE OFADHERENCE MONITOR PATIENTS BLOOD PRESSURE CLOSELY AND NOTIFY MD OF ANY SIGNIFICANT CHANGESINSTRUCT PT TO AVOID OVER-THE-COUNTER COLD AND SINUS MEDS AS THEY CONTAIN VASOCONSTRICTORINST OF HYPERTENSIVE CRISIS MONITOR FOR SS OF ORTHOSTATIC HYPOTENSION
Hypertension
ASSESS PSYCHOLOGICAL STATUS PROVIDE SUPPORTIVE THERAPY PROVIDE REMOTIVATION ASSESSINTERPERSONAL BEHAVIOR ASSIST PATIENT TO DEFINE PROBLEMS amp SOCIAL RELATIONSHIPS GIVE POSITIVEREINFORCEMENT ENCOURAGE PATIENT TO PERFORM PERSONAL HYGIENE amp GROOMING ACTIVITIESASSIST PATIENT TO EXPRESS REALISTIC IDEAS amp PLANS ASSIST PATIENT TO VERBALIZE FEELINGS
Depression
INSTRUCT PATIENT IN CONSEQUENT PHYSICAL L IMITATIONS PLANNING AN ADEQUATE LEVEL OF DAILYACTIVITIES TEACH PT RE ARTHRITIS SS OF EXACERBATION TEACH THE IMPORTANCE OF GOOD POSTUREPREVENT TRAUMA TO JOINTS INST PT IN THE USE OF ASSISTIVE DEVICE AS PRESCRIBED
Osteoarthritis
SKILLED OBSERVATIONEVALUATION ASSESS VITAL SINGS amp SS COMPLICATIONSINSTRUCTEVALUATE UNDERSTANDING OF DISEASE PROCESS DETECTING COMPLICATIONSDIETNUTRITIONAL STATUS SAFETY PRECAUTIONEMERGENCY MEASURES MED-REGIMEN
PSYCH ASSESSMENT ASSESS FOR SS OF EPSDETECT AND ALLEVIATE SOMATIZED COMPLAINTSLIMIT SETTING MOTIVATION TECHNIQUES IMAGERY TECHNIQUES
RELAXATION TECHNIQUESGOAL ORIENTED TASKS
FOLEY INSERTION _______FR FOLEY WITH___________cc BALLONCHANGE Q MONTH amp PRN x3 FOR CLOGGED LEAKING OR ACCIDENTAL REMOVALINST DRESSING CHANGES ________________________ MONITOR FOR SS COMPLICATIONS amp NOTIFY MD
INST SS INFECTION
MONITOR STATUS OF WOUND OR DECUBITUS (place) ______________INST INFECTION CONTROL MEASURES
INST GOOD NUTRITION TO FACILITATE HEALINGMEASURE AND RECORD WOUND or DECUBITUS SIZE AT SOC AND AT LEAST WEEKLY THEREAFTEROPEN WOUND CAREDRESSING CLEANSE WOUND WITH ___________ TO RINSE WITH __________ AND APPLY______________ AND PRN
OBSERVE AND RECORD TYPE AND AMOUNT OF DRAINAGE COLOR INFECTION SWELLING REDNESS PAINDE CUB ITUS CAR EDR ESS ING CLEAN SE W OUN D WITH ___________ TO R IN SE WITH __________ AN D APP LY ______________ AN D PR N
TEACH THE PATIENT HOW TO USE A METERED-DOSE INHALER MAINTAIN EFFECTIVE AIRWAY CLEARANCE
EMPHASIZE THE IMPORTANCE OF ADEQUATE DAILY FLUID INTAKE
PROMOTE AN EFFICIENT BREATHING PATTER
INST INFECTION CONTROL amp PULMONARY HYGIENE INST COMPLICATIONS IN CARDIOPULMONARY STATUSINST PREVENTION OF COMPLICATIONS IE AVOID OVER-EXERTION CHILLING CROWDS ETC
INST D ISEASE PROCESS amp MAINTENANCE
INSTRUCT COUGHING DEEP BREATHING EXERCISES INST PATIENT TO MAINTAIN ADEQUATE REST PATTERN
MANAGEMENT AND EVALUATION OF A PATIENT CARE PLAN TEACHING AND TRAINING DISEASE PROCESS SKIN CARE WOUND CAREDRESSING CHANGE DECUBITUS CARE MEDICATION REGIMEN DIETNUTRITIONHYDRATION COMPLICATIONS OF ENT FEEDING AS INDICATED
PAIN CONTROL MEASURES SYMPTOM CONTROL MEASURES SINGSSYMPTOMS OF INFECTION SAFETYPREVENTION OF INJURY EMERGENCY PLANS OXYGEN ADMINISTRATION
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GOALSREHABILITATION POTENTIAL CMS485 (POC)Included as reference only your Professional Staff must reviewupdatepersonalizeapprove the goals
DISCHARGE PLANNING DISCUSSED WITH PATIENT Yes No REHAB POTENTIAL ExcellentPoor Fair Good
SIGNATUREDATES
X DateStaff Completing the OASIS (signaturetitle)
OASIS INFORMATION
Data Entry Date amp Locked Date SubmittedQA Date Reviewed
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SN - GOALSMRMS _________________ WILL EXHIBIT VITAL SIGNS WITHIN ACCEPTABLE RANGE AND STABILIZED DISEASE PROCESSVERBALIZES KNOWLEDGE OF DISEASE MANAGEMENT MEDICATIONS SIDE EFFECTS PRECAUTIONS DIET FLUIDS TREATMENT PROGRAM SS NECESSITATING MEDICAL ATTENTION EMERGENCY CARE
STABILIZATION OF PSYCHOLOGICAL STATUS WITHIN DISEASE LIMITS TO REDUCE THE PATIENTS ANXIETY LEVELDEPRESIONANXIETY CONTROLED TROUGH MED REGIMEN INTERVENTIONS
ANEMIA CONTROLLED THROUGH MED REGIMEN IMPROVED HEMATOLOGIC STATUS
General
Psychiatric
A n e m i aHEALED WOUND WITHOUT INFECTION OR COMPLICATIONS DEMONSTRATE PROPER WOUND CARE
Wound Care
PTSO SHOULD UNDERSTAND THE NATURE SYMPTOMS STAGE AND PROGRESSION OF ALZHEIMERS DISEASEKNOW HOW TO RECOGNIZE PTS OWN STRESS AND WAYS TO PREVENT OR REDUCE IT PROMOTE SOCIAL INTERACTION AS TOLERATED BY THE PATIENT
Decubitus
DEMONSTRATE STRATEGIES TO BE USED DURING A COUGHING EPISODE HELP THE PATIENT IDENTIFY FACTORSTHAT MAY CAUSE ASTHMA ATTACKS OR CONTRIBUTE TO THEMAsthma
SAFELY ADMINISTERS INJECTION COMPREHEND RATIONALE FOR AND IS ABLE TO ROTATE INJECTION SITESCOMPREHEND SAFETY FACTORS IN SYRINGENEEDLE DISPOSALPATIENTCG ABLE TO MONITOR BLOOD SUGAR CORRECTLY WITHOUT ASSISTANCEABLE TO NOTIFY MD OF ALTEREDOUT OF RANGE RESULTS
InsulinGlucometer
DISCHARGE PT WHEN BLOOD SUGARS ARE WITHIN THE NORMAL FOR PATIENT RANGEKNOW THE ACCEPTABLE RANGE FOR BLOOD SUGAR LEVEL COMPLY WITH DIET RESTRICTIONS Diabetes
MellitusRETURN TO SELF-MANAGEMENT OF HEALED FRACTURED
FractureKNOW ABOUT SIGNS SYMPTOMS AND PRECIPITATING CAUSES OF CHF KNOW HOW TO TAKE THE PULSE AND KNOWTO CONSULT THE DOCTOR BEFORE CONTINUING MEDICATION IF THE PULSE RHYTHM CHANGES KNOW TOA V O I D S M O K I N G A N D S M O K Y E N V I R O N M E N T S A N D P E R S O N S W I T H I N F E C T I O N S E S P E C I A L L Y R E S P I R A T O R Y I N F E C T I O N S
CHF
UNDERSTAND THAT HYPERTENSION IS A CHRONIC DISEASE REQUIRING LIFE LONG TREATMENT EXHIBIT BLOODPRESSURE READINGS CONSISTENTLY WITHIN NORMAL OR SPECIFIED RANGE DEMONSTRATE ADHERENCE TO ALOW-SALT LOW-FAT DIET
Hypertension
HELP THE PATIENT ACHIEVE PAIN RELIEVE AND REDUCE ANGINA EPISODES UNDERSTAND THE CAUSE OFANGINA PECTORIS AND POSSIBLE PRECIPITATING FACTORS FOR AN ATTACK IDENTIFY PERSONAL STRESSORSTHAT MAY CONTRIBUTE TO THE PROBLEM AND BEGIN ELIMINATING OR MINIMIZING THEM KNOW WAYS TOREDUCE THE FREQUENCY OF ANGINA EPISODES
Angina
HEALED DECUBITUS WITHOUT INFECTION OR COMPLICATIONS DEMONSTRATE PROPER DECUBITUS CARE
Alzheimers
UNDERSTAND SS OF BRONCHITIS OR OTHER RESPIRATORY INFECTION AND DISEASE EXACERBATIONUNDERSTAND THE DANGERS OF SMOKING AIR AND CHEMICAL POLLUTANTS AND RESPIRATORY INFECTIONUNDERSTAND AND PRACTICE COUGHING AND DEEP-BREATHING EXERCISES
Respiratory
DAILY COMPLIANCE WCATHETER CARE DECREASE RISK OF URINARY INFECTIONCatheter
INCREASED PAIN RELIEF INCREASED STRENGTH AND ENDURANCE COMPREHEND AND DEMONSTRATE HOME EXERCISEOsteoarthritis
AIDE - GOALS
GAIT PATTERN ENDURANCE STRENGTH AND BALANCE WILL IMPROVE AND PATIENT WILL DEMONSTRATECORRECT BODY MECHANICS WIN 4-6 WKS PTCG WILL COMPREHEND AND DEMONSTRATE HOME EXERCISEPROGRAM WITHIN 4-6 WKS
FAIR-TO BE ABLE TO CARRY OUT MINIMAL ADLS WITH AVAILABLE HOME SUPPORTWILL NOT BE ABLE TO CARRY OUT ADLS WITHOUT MAXIMUM SUPPORT
RETURN TO INDEPENDENT AMBULATION BE SAFE IN SELF CAREPATIENT WILL BE ABLE TO FUNCTION WITH ASSISTANCE OF CAREGIVERWITHIN HESHE CURRENT LIMITATIONS AT HOME
PATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HISHER CURRENT LIMITATIONS AT HOME
PT - GOALS
GOOD RETURN TO PREVIOUS LEVEL OF ADLS INDEPENDENTLY
GAIT PATTERN ENDURANCE STRENGTH AND BALANCE WILL IMPROVE AND PT WILL DEMONSTRATECORRECT BODY MECHANICS WITHIN _____ WEEKS
PATIENT WILL EXPERIENCE A DECREASE IN PAIN
PTCG WILL COMPREHEND AND DEMONSTRATE HOME EXERCISEPROGRAM WITHIN _____ WEEKS
OT PATIENT WILL EXHIBIT IMPROVEMENT IN COPING IN ADLSIADLS MUSCLE USEMOTORCOORDINATIONNEURO RESPONSEUSE OF ORTHOTIC SPLINTING ANDOR EQUIPMENT
OT - GOALS
PATIENT WILL DEMONSTRATE FUNCTIONAL COMMUNICATIONS EXHIBIT MAXIMUM VERBAL AND SENTENCEFORMULATION AND COMPREHENSION WITHIN DISEASE LIMITS WITHIN _____ WEEKS
ST - GOALS
PATIENT WILL DEMONSTRATE APPROPRIATE USE OF FUNCTIONAL VERBALNON-VERBALCOMMUNICATIONS SYSTEMS WITHIN _____ WEEKS
PATIENT WILL DEMONSTRATE IMPROVED READINGWRITING USE OF GESTURESNUMBERS WITHIN _____ WEEKS
PATIENT WILL DEMONSTRATE IMPROVED SWALLOWINGCHEWINGORALMOTOR CONTROL WITHIN _____ WEEKS
PATIENT WILL HAVE ADEQUATE SUPPORT TO REMAIN IN HOME WITH ASSISTANCE OF COMMUNITYRESOURCES FOR FINANCIAL TRANSPORTATION AND PERSONAL CARE ASSISTANCE WITHIN _____ WEEKS
MSW - GOALSPSYCHOSOCIAL EVALUATION WILL BE PERFORMED PTCG WILL BE COUNSELED REGARDING MANAGEMENTamp ADJUSTMENT TO ILLNESS LONG TERM PLANNING AND DECISION MAKING APPROPRIATE COMMUNITYRESOURCE REFERRALS WILL BE MADE
WILL DISCHARGE THE PATIENT WITHIN 60 DAYS WHEN PATIENT ANDORCAREGIVER ISARE ABLE TO DEMONSTRATE KNOWLEDGE OF DISEASE MANAGEMENT SS COMPLICATIONSPATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HISHER CURRENT LIMITATION AT HOME
ABLE TO REMAIN IN HOMERESIDENCEALF WITH ASSISTANCE OF PRIMARY CAEGIVERSUPPORT AT HOMEABLE TO UNDERSTAND MEDICATION REGIMEN AND CARE RELATED TO HISHER DISEASEWILL BE DISCHARGE WHEN MAXIMUM FUNCTIONAL POTENTIAL REACHED
Patient Name Med Record
wwwpnsystemcom 3058185940 The Outcome and Assessment Information Set (OASIS) is the intellectual property of the Center for Health Services and Policy Research Denver Colorado It is used with permission Expiration date 7312012
XPatient Signature if required optional if itinerary is used
SA
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- OASIS_C_SOC
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- PT ID PERFORMED VIA NAME DOB FACE RECOGNITION AND ADDRESS BEFORE SERVICE PROVIDED Off
- TIME IN
- TIME OUT
- Agency Name SALUD HOME CARE INC
- Phone 305-555-5555
- Employees NameTitle Completing the OASIS
- who has signed the plan of care
- Physician name
- Address 1
- Address 2
- Phone Number
- Address 1_2
- Address 2_2
- Patient Phone
- Reason
- Name
- Other Physician if any
- Phone_2
- Address 1_3
- Address 2_3
- Phone Number_2
- REFERRAL SOURCE if not from Primary Physician
- undefined_6
- Phone_3
- Fax
- Evacuation Form needed Emergency Reg 1
- Evacuation Form needed Emergency Reg 2
- EMERGENCY CONTACT
- Address
- Comments 1
- Comments 2
- Phone_4
- Relationship
- OTHER
- Comment 1
- Comment 2
- 11 Other specify
- a
- b
- 7 Other specify
- c
- d
- e
- f
- a_2
- b_2
- d_2
- e_2
- f_2
- a_3
- b_3
- d_3
- Comment if needed 1
- Comment if needed 2
- a_4
- a_5
- a_6
- Date 23
- undefined_7
- undefined_8
- b_4
- b_5
- b_6
- Date_2
- undefined_9
- undefined_10
- Date_3
- undefined_11
- undefined_12
- d_4
- d_5
- d_6
- Date_4
- undefined_13
- undefined_14
- Date_5
- undefined_15
- undefined_16
- Date_6
- undefined_17
- undefined_18
- 12 1
- 12 2
- Date_7
- undefined_19
- undefined_20
- Date_8
- undefined_21
- undefined_22
- MAIN REASON FOR HOME HEALTH CARE 1
- MAIN REASON FOR HOME HEALTH CARE 2
- Fractures site
- Surgeries site
- Cancer site
- Open Wound site
- Decubitus site
- Other specify
- Other
- Pending or Needed
- Yes Number of times
- Reason s Dates
- MobilityAmbulatory devices used
- Other specify_2
- undefined_23
- Comments if needed 1
- Comments if needed 2
- Comments if needed 3
- Comments if needed 4
- undefined_24
- Name_2
- Phone number if different from patient
- Relationshiphealth statusability to help 2
- Any paid help explain
- Specify 1
- Specify 2
- Specify 3
- Any ears surgeryprocedure
- Date_9
- Otherspecify 1
- Otherspecify 2
- Other agencies involved in care 1
- Other agencies involved in care 2
- 1
- 2
- Other_2
- Infections
- Cataract surgery Site
- Date_10
- Other eyes surgery Site
- Date_11
- explain 1
- explain 2
- Any nose surgery
- Date_12
- Other specify_3
- 1_2
- 2_2
- MassesTumors site
- Lesions explain
- Any surgeryprocedure
- Other specify 1
- Other specify 2
- Other specify 3
- Date_13
- Other specify_4
- No Problem
- Medication
- Other_3
- Pain control treatmentmeds Side effect mark
- Other_4
- Is there a regular pattern to the pain explain
- Other_5
- Comment
- What was the outcome
- Type II OnsetExacerbation date
- DietOral control specify
- INSULIN dosage frequency scale explain
- 1_3
- 2_3
- Since
- Other_6
- A1c
- BS
- mgdL DateTime
- Blood sugar ranges
- site 1Location site
- site 2Location site
- site 3Location site
- Frequency
- Other_7
- site 1New Onset Exacerbation
- site 2New Onset Exacerbation
- site 3New Onset Exacerbation
- Able to use Glucometer
- site 1Present level 010
- site 2Present level 010
- site 3Present level 010
- Diabetes Management Problems explain 1
- Diabetes Management Problems explain 2
- Other Endocrine problems
- site 1Occasional y Cont Intermittent Frequency Frequently
- site 2Occasional y Cont Intermittent Frequency Frequently
- site 3Occasional y Cont Intermittent Frequency Frequently
- site 1Pain type ach ng burn ng rad ating neura gia etc
- site 2Pain type ach ng burn ng rad ating neura gia etc
- site 3Pain type ach ng burn ng rad ating neura gia etc
- Anemia specify type if known
- site 1Feeling of pain internal external acute chronic
- site 2Feeling of pain internal external acute chronic
- site 3Feeling of pain internal external acute chronic
- site 1Pain is worse morning
- site 2Pain is worse morning
- site 3Pain is worse morning
- Immunodeficiency problems explain
- Other 1
- Other 2
- Other_8
- explain 1_2
- explain 2_2
- explain 3
- explain 4
- Other specify 1_2
- Other specify 2_2
- undefined_25
- undefined_26
- undefined_27
- undefined_28
- undefined_29
- undefined_30
- undefined_31
- undefined_32
- undefined_33
- undefined_34
- undefined_35
- undefined_36
- M1310 Pressure Ulcer Length Longest length headtotoe
- undefined_37
- cm
- greatest width perpendicular to the length
- M1314 Pressure Ulcer Depth Depth of the same pressure ulcer from
- cm_2
- visible surface to the deepest area
- undefined_38
- cm_3
- 1_4
- 2_4
- 3_2
- Other_9
- 4_2
- Caregiver name
- Other_10
- cant integument findings
- Observation
- Observation_2
- Caregiver name_2
- Other_11
- Wound cleaned with specify
- Wound irrigated with specify
- 1 Size
- cm width
- Wound packed with specify
- Location
- Other_12
- Wound dressingcover applied specify
- 2 Size
- cm width_2
- Comments 1_2
- Comments 2_2
- Location_2
- Other_13
- Sizecm LengthxWidthxDepth
- Sizecm LengthxWidthxDepth_2
- Diagram 4Sizecm LengthxWidthxDepth
- Tunneling Undermining cm
- Tunneling Undermining cm_2
- Diagram 4Tunneling Undermining cm
- Stage IIIIIIIV pressure uIcers only
- Diagram 4Stage IIIIIIIV pressure uIcers only
- Odor Fool normal etc
- Diagram 4Odor Fool normal etc
- Edema pedal sacral p tting etc
- Diagram 4Edema pedal sacral p tting etc
- Appearance of the Wound Bed
- Diagram 4Appearance of the Wound Bed
- Treatment Ordered
- Diagram 4Treatment Ordered
- Other_14
- Other_15
- Other_16
- Other_17
- Yes 1
- Yes 2
- Yes 3
- Height
- Weight
- Radiating to
- GainLoss
- lb X
- Frequencyduration
- Sittinglying R
- L
- Standing R
- L_2
- Medication_2
- Temperature
- Other_18
- Apical
- Brachial
- Radial
- Carotid
- Dependent
- Pitting 1234
- Respirations
- Site
- Cramps site
- Disease Management Problems explain
- Right Upper
- Right
- Right Lower
- 1_5
- 2_6
- 3_3
- Left
- Left Upper
- Left Lower
- Pacemaker Date
- Last date checked
- SOB on minimal effortwalk
- Type
- fy
- Other Prob 1
- Other Prob 2
- O2
- Trach sizetype
- CaregiverfamilyOther
- Yes explain 1
- Yes explain 2
- Other_19
- Comments 1_3
- Comments 2_3
- Increase fluids
- Restrict fluids
- Frequency_2
- Amount
- Yes describe 1
- Yes describe 2
- Frequency_3
- Other 1_2
- Other 2_2
- Nocturia x
- Bowel Off
- undefined_52
- Diapersother
- Other_20
- No
- 2TOTAL
- Urinary Catheter Type
- Last changed on
- Foley inserted date
- with
- Inflated balloon with
- Irrigation solution Type specify
- Amount_2
- mL Frequency
- Returns
- No_2
- 1_6
- 2_7
- Describe at risk intervention and plan 1
- Describe at risk intervention and plan 2
- Describe at risk intervention and plan 3
- DischargeDrainage describe
- Lesions
- Blisters
- Masses
- Cysts
- Wart
- Other specify_5
- Surgical alteration
- Prostate problem BPH TURP Date
- undefined_53
- undefined_54
- Selftesticular exam Frequency
- Hysterectomy Date
- undefined_55
- undefined_56
- Date last PAP
- undefined_57
- undefined_58
- Results
- Breast selfexam frequency
- Mastectomy R L Date
- undefined_59
- undefined_60
- Other specify_6
- Last BM
- Diarrhea Frequency
- Bowel regimeprogram
- Incontinence Off
- Urinary Off
- Diapersother_2
- Other_21
- te describe skin around stoma
- Ileostomycolostomy s 2
- Ileostomycolostomy s 3
- Ileostomycolostomy s 4
- Ileostomycolostomy s 5
- Headache Location
- Frequency_4
- Other_22
- Migraine Frequency
- Site_2
- Weakness UE LE Location
- Other specify_7
- Site_3
- IV
- Pump typespecify
- Hand grips Equal Unequal specify
- Feedings Type amtrate
- Strong Weak specify
- Psychotropic drug use specify
- Flush Protocol amtspecify
- DoseFrequency
- Other_23
- Other specify 1_3
- Other specify 2_3
- DressingSite care specify 1
- DressingSite care specify 2
- Interventions instructionsComments 1
- Interventions instructionsComments 2
- Following Un
- versalStandard precautions
- NA
- No Problem_2
- Pain Frequency
- Abdominal girth
- Bowel sounds active absent hypo hyperactive x
- 3 Forgetful Off
- 4 Depressed Off
- 6 Lethargic Off
- 5 Disoriented Off
- 7 Agitated Off
- 2 Comatose
- 8 Other Off
- Forgetful at times Off
- Irritable Off
- Anxious Off
- Alert Off
- Describe 1
- Describe 2
- undefined_61
- Needs interpreter
- Comments 1_4
- Comments 2_4
- Higher Educational Level
- Fracture location
- Swollen painful joints specify
- Explain
- Contractures Joint
- Spiritual resource
- Location_3
- Phone No
- Atrophy
- Other_27
- Explain 1
- Explain 2
- Decreased ROM
- Paresthesia
- Weakness
- Other_28
- Inappropriate followthrough in past
- Amputation BKAKUE RL specify 1
- Amputation BKAKUE RL specify 3
- Amputation BKAKUE RL specify 4
- Treatment
- Treatment_2
- Other specify 1_4
- Other specify 2_4
- History of Falls past 3 months 12 falls M1032
- V s on Status Poor w or w o glasses M1200
- Vision Status Poor Legally blind M1200
- Gait and Balance Balance problem while standing
- Gait and Ba ance Balance problem while walking
- Gait and Balance Decreased muscular coordination
- Pred spos ng D seases 12 present
- Predisposing D seases 3 or more present
- Equipment Issues Oxygen tubing
- 1Row1
- PlanComments 1
- PlanComments 2
- Comment_2
- undefined_62
- b Ambulation
- c Transfer
- DOther specify
- 7Independent in home 1
- 7Independent in home 2
- Other 1_3
- Other 2_3
- Typebrand
- Size
- Gauge
- Length
- Insertion site
- Insertion date
- Flush solution
- Frequency_5
- Injection cap change frequency
- Dressing change frequency
- Other_29
- Siteskin condition
- External catheter length
- OtherComment
- fluid overload Other
- Circumference of arm
- Huber gaugelength
- Yes date
- Last flushed date
- Siteskin condition_2
- Infusion solution typevolumerate
- Dressing
- OtherComment 1
- OtherComment 2
- Drug Name
- Dose
- Route
- Frequency_6
- Duration of therapy
- Drug Name_2
- Dose_2
- Route_2
- Frequency_7
- Duration of therapy_2
- CommentPlan 1
- CommentPlan 2
- Pump type specify
- Other_30
- Lab draws
- Infusion care provided during visit 1
- Infusion care provided during visit 2
- Infusion care provided during visit 3
- Antibiotic therapy
- 1_7
- 2_8
- Other_31
- Removing line date if know
- BraceOrthotics specify 1
- BraceOrthotics specify 2
- BraceOrthotics specify 3
- Needs specify 1
- Needs specify 2
- Oxygen HME Co
- Prosthesis RUE RLE LUELLEOther
- HME Rep
- Grab bars BathroomOther
- Hospital bed Semielec Crank Spec
- Other_32
- NA_2
- Phone_5
- n care
- PlanComments
- N
- Other_33
- undefined_63
- Physical Therapy Total visits
- Speech Therapy Total visits
- visits
- Other Therapy Total visits
- Patient is not assessed to be at risk for falls
- No pain identified
- Patient has no pressure ulcers with need for moist wound healing
- O
- Noncompliance with drug orders
- Expected Outcome
- Patient unable to perform own Wound Care due
- Pat
- to
- Abd Pads Off
- Underpads size
- undefined_68
- Special mattress overlay
- Angiocatheter size
- Ostomy pouch brand size
- Pressure relieving device
- Ostomy wafer brand size
- undefined_69
- SYRINGES
- Batteries size
- Skin protectant
- Glucometer
- Hydrocolloids
- undefined_70
- FOLEYCATH SUPPLIES
- Syringes size
- size
- Oxygen concentrator
- Feeding tube
- Ointment
- Acetic acid
- Other 1_4
- Other 2_4
- Other 3
- Tens unit
- KLING 4
- Other 1_5
- Other 2_5
- Other 3_2
- PatientCG educationteaching this visit for
- MEDICATION Off
- DISEASE PROCESS COMPLICATIONS Off
- undefined_71
- SS OF Off
- ILEAL CONDUITOSTOMY Off
- DIET FLUIDS Off
- undefined_72
- undefined_73
- SKINFOOT CARE Off
- INFECTION CONTROL Off
- OTHER INSTRUCTIONS GIVEN
- Caregiver present during the visit
- NEEDS FURTHER TEACHING Off
- No_3
- Skilled Observation Assessment
- ent Educat
- Wound Care Dress
- Diabetic Observation Care
- Correct handwashing technique followed SG 1
- Correct handwashing technique followed SG 2
- Correct handwashing technique followed SG 3
- Correct handwashing technique followed SG 4
- 21 Included as reference only your Professional Staff must reviewupdatepersonalizedapprove the orders
- SN ORDERS FREQUENCYDURATION
- S COMPLICATIONS
- TH GLUCOMETER OR
- ON
- TEACH GLUCOMETER OR
- NSERTION
- TH
- INST DRESSING CHANGES
- MONITOR STATUS OF WOUND OR DECUBITUS place
- ADMINISTER PRESCRIBED INJECTABLE
- USING
- TH_2
- TH_3
- AND APPLY
- CLEANSE WOUND WITH
- NSE WITH
- AND APPLY_2
- OTHER_2
- DE ORDERS FREQUENCYDURATION
- PT ORDERS FREQUENCYDURATION
- OT ORDERS FREQUENCYDURATION
- ST ORDERS FREQUENCYDURATION
- MSW ORDERS FREQUENCYDURATION
- Included as reference only your Professional Staff must reviewupdatepersonalizeapprove the goals 22
- MRMS
- PROGRAM WITHIN
- CORRECT BODY MECHANICS WITHIN
- COMMUNICATIONS SYSTEMS WITHIN
- undefined_75
- undefined_76
- Date_14
- QA Date Reviewed
- undefined_77
- undefined_78
- Data Entry Date Locked
- undefined_79
- undefined_80
- Date Submitted
- undefined_81
- undefined_82
- SOCD
- SOCM
- SOCY
- SOCM1
- SOCD1
- SOCY1
- Check Box2 Off
- Check Box3 Off
- Check Box4 Off
- TOM
- TOD
- TOY
- FDM
- FDD
- FDY
- Prov 1071523
- BrID
- Check Box9 Yes
- BrIDno
- Check Box11 Off
- DLCM
- DLCD
- DLCY
- LVM
- LVD
- LVY
- DNR1 Off
- Check Box19 Off
- STFL
- PZC
- MCN
- NOMC Off
- SSN1
- SSN2
- SSN3
- SSUK Off
- MAN
- MAUK Off
- DOBM
- DOBD
- DOBY
- SEX Off
- MR
- First
- MI
- Last
- Suffix
- RACE2 Off
- RACE3 Off
- RACE4 Off
- RACE5 Off
- RACE1 Off
- RACE6 Off
- PS3 Off
- PS0 Off
- PS1 Off
- PS4 Off
- PS5 Off
- PS6 Off
- PS7 Off
- PS8 Off
- PS9 Off
- PS10 Off
- PS11 Off
- PS2 Off
- PSUK Off
- Ecode
- COMP Off
- DACM
- DACD
- DACY
- REA Off
- DM
- DD
- DY
- RDM
- RDD
- RDY
- REFDM
- REFDD
- REFDY
- EPT Off
- 14D2 Off
- 14D3 Off
- 14D4 Off
- 14D5 Off
- 14D6 Off
- 14D7 Off
- 14D8 Off
- Check Box39 Off
- icd9c
- icd9a
- icd9b
- icd9d
- icd9e
- icd9f
- Check Box5 Off
- Check Box7 Off
- icd9b2
- icd9c2
- icd9d2
- C_2
- icd9e2
- icd9f2
- icd9a2
- icd9b3
- icd9c3
- C_3
- icd9a3
- icd9d3
- 1005d
- 1005m
- 1005y
- 1018-2 Off
- 1018-1 Off
- 1018-4 Off
- 1018-5 Off
- 1018-6 Off
- 1018-7 Off
- 1018-NA Off
- 1018-UK Off
- 1018-3 Off
- 1012-na Off
- 1012-uk Off
- Radio Button11 Off
- v1020b
- C_5
- e_5
- f_5
- C_6
- e_6
- f_6
- c_4
- e_4
- f_4
- v1020c
- v1020d
- v1020e
- v1020f
- v1020a
- e1020b
- e1020c
- e1020d
- e1020e
- e1020f
- e1020a
- ev1020b
- ev1020c
- ev1020d
- ev1020e
- ev1020f
- ev1020a
- sp12-1
- sp12-2
- Radio Button12 Off
- Radio Button13 Off
- rad0 Off
- rae0 Off
- rdf0 Off
- phhp Off
- phrp1 Off
- phot1 Off
- phoa1 Off
- phfc1 Off
- phca1 Off
- phin1 Off
- phga1 Off
- phif1 Off
- phsg1 Off
- phwd1 Off
- phdc1 Off
- phgn1 Off
- rddmi Off
- imin Off
- inh1n1 Off
- fwpn Off
- fwtn Off
- fwot Off
- phdm1 Off
- PHNY Off
- phcd1 Off
- 10304 Off
- 10301 Off
- 10302 Off
- 10303 Off
- 10327 Off
- M1034 Off
- HBR1 Off
- HBR2 Off
- HBR3 Off
- HBR4 Off
- HBR5 Off
- HBR6 Off
- HBR7 Off
- HBR8 Off
- HBR9 Off
- HBR11 Off
- HBR12 Off
- HBR10 Off
- HBR13 Off
- SOBFT
- 10321 Off
- 10322 Off
- 10333 Off
- 10324 Off
- 10325 Off
- 10336 Off
- M11001 Off
- M1100b Off
- M1100c Off
- Relationshiphealth statusability to help 1
- 10361 Off
- 10362 Off
- 10363 Off
- 10364 Off
- 10365 Off
- 10366 Off
- 1210d Off
- 1210an Off
- 1210hea Off
- 1210OTH Off
- 1210TIN Off
- 1210NP Off
- 12102 Off
- 12101 Off
- 1210uk Off
- 1210h Off
- 1210v Off
- 1200CAT Off
- 1200OTH Off
- 1200JA Off
- 1200CATRL Off
- 1200OTHER Off
- 1200PT Off
- 1200GLAU Off
- 1200NOP Off
- NOSECON Off
- NOSEEP Off
- NOSELS Off
- NOSESINP Off
- NOSEASG Off
- NOSEOTHSP Off
- NOSENP Off
- THROATDY Off
- TROATL Off
- THROATOTH Off
- 1200BV Off
- 1200LB Off
- THROATHO Off
- THOATSO Off
- THROATNP Off
- 1200GL Off
- 1200CO Off
- 1200PR Off
- 1200IN Off
- M1200 Off
- M1220 Off
- M1230 Off
- MOUTHMas Off
- MOUTHGI Off
- MOUTHULC Off
- MOUTHTOO Off
- MOUTHANY Off
- MOUTHOTH Off
- MOUTHNP Off
- M1240 Off
- M1242 Off
- MOUTHDE Off
- MOUTHUP Off
- MOUTHLO Off
- MOUTHPAR Off
- COPYN Off
- MKMEDP Off
- CPCYN Off
- DPRYN Off
- ICPYN Off
- TURGGP Off
- BESTPAINSC2
- WORSES2
- BESTPAINSC
- WORSESC
- BESTPAINSC3
- WORSESC3
- FACESOBS Off
- SCALE010 Off
- WPSL Off
- WPMA Off
- WPMV Off
- WPAMB Off
- WPIMM Off
- WPTR Off
- WPOTH Off
- WPNP Off
- NVIM Off
- WRP4 Off
- WRP5 Off
- WRP6 Off
- WRP7 Off
- WRP8 Off
- WRP9 Off
- WRPOTH Off
- TKMEDNV Off
- TKMEDLDD Off
- TKMEDD Off
- TKMED23 Off
- TKMEDLT3 Off
- PCTSL Off
- PTXSEN Off
- PTXSEV Off
- PTXSECF Off
- PRDOCC Off
- PTXSEOTH Off
- PRDCONT Off
- WRP1 Off
- WRP2 Off
- WRP3 Off
- PRDINT Off
- PRDFRQ Off
- PHYNOTPT Off
- PHYNOTSTF Off
- NVIG Off
- NVIC Off
- NVIAF Off
- DMIJUV Off
- DMTPII Off
- INSDGFQ Off
- DMODIET Off
- ADMOTH Off
- symphyg Off
- sympfat Off
- symhypog Off
- endopcgr Off
- endopostpra Off
- endorand Off
- endolab Off
- bsrange Off
- bsranptcg Off
- endomonsf Off
- endomoncg Off
- endomonsn Off
- endomonoth Off
- dmNapb Off
- othendopb Off
- enlthyr Off
- intoheatcol Off
- endonp Off
- HEMAANE Off
- HEMABLEED Off
- HEMAHEMO Off
- HEMAINMO Off
- HEMAOTH Off
- HEMANP Off
- SKINITCH Off
- SKINRASH Off
- SKINDRY Off
- SKINSCL Off
- SKINRED Off
- SKINBRU Off
- SKINECCH Off
- SKINPALL Off
- SKINJAU Off
- ADMSELF Off
- ADMSCGF Off
- ADMNURS Off
- SKINNP Off
- m1300 Off
- M1302 Off
- M1306 Off
- M1320 Off
- M1322 Off
- M1324 Off
- M1330 Off
- M1332 Off
- M1334 Off
- M1340 Off
- M1342 Off
- M1350 Off
- WCPYN Off
- IPDMYN Off
- APHYN Off
- SDRBY Off
- SDRSN Off
- SDRCG Off
- SDRPT Off
- SDROTH Off
- TECST Off
- TECCL Off
- WDCLW Off
- WDIRRW Off
- WDPKW Off
- WDDREW Off
- DBFEXD Off
- DBFEX2D Off
- DBFEXEOD Off
- DFEX2WK Off
- DBNFEXWK Off
- DFEXOTH Off
- PDPPRL Off
- PDPARL Off
- LSWRL Off
- endobm Off
- endotv Off
- fbs Off
- LSCDRL Off
- ASCCFR Off
- ASCCFL Off
- Right for
- ASCCFLF
- TRINR Off
- BURRL Off
- LEGHP Off
- LEGHAB Off
- DBFEXRN Off
- DFEXCG Off
- DBFEXPT Off
- DBFEXOT Off
- EXSER Off
- EXSERG Off
- EXSANG Off
- EXSER2 Off
- EXSERG2 Off
- EXSANG2 Off
- SHOV Off
- SHAPRD Off
- SHAPOTH Off
- SHOV2 Off
- SHAPRD2 Off
- SHAPOTH2 Off
- cm length
- cm length2
- DBFTEXRNPT Off
- EXDYN Off
- EXDYN2 Off
- APHYN2 Off
- APHYN3 Off
- Loc3w
- Loc2w
- Loc1w
- Loc4w
- Typew1
- Typew2
- Typew3
- Typw4
- sizw3
- tunnw3
- surrw1
- stomaw1
- surrw1a
- stomaw1a
- surrw3
- surrw3a
- stomaw3
- stomaw3a
- surrw2
- surrw2a
- stomaw2
- stomaw2a
- surrw4
- surrw4a
- stomaw4
- stomaw4a
- statgew2
- statgew3
- Odorw2
- Odorw3
- Edemaw2
- Edemaw3
- appw2
- appw3
- Treatment Ordered_2
- Treatment Ordered_3
- Group10 Off
- draick2 Off
- driack3 Off
- draick4 Off
- colw11 Off
- colw12 Off
- colw31 Off
- colw32 Off
- colw33 Off
- colw34 Off
- colw21 Off
- colw22 Off
- colw23 Off
- colw24 Off
- colw43 Off
- colw44 Off
- ital1u1 Off
- ital1u2 Off
- fsrrepo Off
- frsact Off
- rwgchpt Off
- rwgchcgf Off
- rwgchnur Off
- pulreg1 Off
- pulirreg1 Off
- fsrrespreg Off
- colw41 Off
- colw42 Off
- bpsitly Off
- bpstand Off
- fsrwgrep Off
- fsrwgact Off
- tempaxil Off
- temptymp Off
- pulseappical Off
- pulseradial Off
- pulsebrach Off
- pulsecarot Off
- pulserest Off
- pulsecheyn Off
- pulseactiv Off
- respirirreg Off
- respideath Off
- respaccess Off
- respiapnea Off
- bsckrack Off
- temporal Off
- temprect Off
- chestprad Off
- colw13 Off
- colw14 Off
- consth2 Off
- consthic2 Off
- consth3 Off
- consthic3 Off
- consth4 Off
- consthic4 Off
- chestpyes Off
- chestpainno Off
- consth1 Off
- consthic1 Off
- cpsubstern Off
- cpviselike Off
- dm5lin
- assocwithsoboe Off
- associawactv Off
- associwsweat Off
- cphowreloth Off
- cphowrelrest Off
- cphowrelmeds Off
- cppalarr Off
- cppalpfast Off
- cppalpslow Off
- cppalpfatig Off
- cpedema Off
- cpedemapedal Off
- cpangina Off
- cppostural Off
- cplocalized Off
- cpedempedrig Off
- cpedemapedallef Off
- cpedemasacral Off
- cpedemadepend Off
- cpedemapitt Off
- cpedemanonpitt Off
- cstcramp Off
- cardstclaud Off
- cardstcapref Off
- cstcaprefless Off
- castcaprefgreat Off
- csthsreg Off
- csthsirreg Off
- csthsmurmur Off
- cstpacemak Off
- cpstabreassouclear Off
- breassodwheez Off
- bresddimm Off
- chestpaidull Off
- cpache Off
- cpsharp Off
- brsdabset Off
- brsdsobsoboe Off
- brsdsobonmineff Off
- 14001 Off
- 14003 Off
- 14004 Off
- 1400tva Off
- 14002 Off
- 1400car Off
- 14101 Off
- 14102 Off
- 14103 Off
- 14104 Off
- uroops Off
- uropat Off
- urocare Off
- 14000 Off
- urosn Off
- Radio Button2 Off
- 16100 Off
- 16101 Off
- 1400pat Off
- 16concar Off
- 162gm Off
- 16nas Off
- 16npo Off
- 16102 Off
- 161800cal Off
- 16lowfat Off
- 16lowcho Off
- 16incflu Off
- 16restflu Off
- 16exc Off
- 16good Off
- 16fair Off
- 16poor Off
- 16anore Off
- 16nau Off
- 16vom Off
- 16heabur Off
- O2satur
- O2firesaf Off
- O2sn Off
- O2carefamother Off
- O2cough Off
- O2no Off
- O2yes Off
- O2nonprod Off
- O2noc Off
- O2yesc Off
- O2dys Off
- O2rest Off
- O2dADL Off
- O2sliplo Off
- O2nop Off
- O2yesp Off
- 16other Off
- genibur Off
- genihes Off
- genihema Off
- geniolig Off
- geniurg Off
- geninoc Off
- geniincon Off
- geniuri Off
- genidiap Off
- 16lowna Off
- genicyell Off
- genicamber Off
- genicbr0 Off
- genicbt Off
- genicother Off
- genicla Off
- geniclo Off
- genised Off
- geniodno Off
- genifol Off
- geniwitdif Off
- genisup Off
- geniyes Off
- genino Off
- 1620 Off
- 1615 Off
- 1630 Off
- 1630cosn Off
- 1630lBM Off
- 1630diar Off
- 1630rect Off
- 1630hemo Off
- 1630incon Off
- 1630diap Off
- 1630lax Off
- 1630w Off
- 1630d Off
- 1630m Off
- 1630lleost Off
- 1630pat Off
- 1630car Off
- 1630sn Off
- 1630ot Off
- 1630np Off
- 1630follow Off
- genblis Off
- genmass Off
- gencys Off
- genwart Off
- geninf Off
- gensurg Off
- genprost Off
- gensef Off
- genmeno Off
- genhyst Off
- gendisc Off
- geniodyes Off
- gennp Off
- 1630flat Off
- 17001 Off
- 17002 Off
- 17004 Off
- 1700head Off
- 1700perr Off
- 1700up Off
- 1700apha Off
- 1700rec Off
- 1700exp Off
- 1700mot Off
- 1700gro Off
- 1700dom Off
- 1700weak Off
- 1700trem Off
- 1700fine Off
- 1700gross Off
- 1700paral Off
- 1700stu Off
- 1700halluc Off
- 1700psy Off
- 1700oth Off
- 1700np Off
- EFAD TPN Off
- 17003 Off
- EFAD jej Off
- EFAD iv Off
- EFAD pum Off
- EFDA bol Off
- EFDA con Off
- EFA pat Off
- EFDA sn Off
- EFDA car Off
- EFDAoth Off
- EFDAfu Off
- EFDA na Off
- EFDA np Off
- abd pa Off
- ABD dis Off
- ABD hard Off
- ABD soft Off
- ABD asc Off
- ABD ab Off
- ABD oth Off
- ABD bow Off
- ABD other Off
- ABD ten Off
- EFAD Nas Off
- efad gas Off
- EFAD ot Off
- 17101 Off
- 17102 Off
- 17103 Off
- 17104 Off
- 17105 Off
- 17100 Off
- 1720 Off
- gen dis Off
- genbre Off
- genmast Off
- genoth Off
- 1700fin Off
- 1700mig Off
- genles Off
- 1630 other Off
- 1730 Off
- 1745 Off
- 1750 Off
- 17450 Off
- 1730a Off
- 1730b Off
- 17000 Off
- 17401 Off
- 17402 Off
- 17404 Off
- 17405 Off
- 17406 Off
- 17407 Off
- 1 Oriented Off
- msnp Off
- pslb Off
- psni Off
- psd Off
- psnas Off
- lbm Off
- lbps Off
- lbph Off
- lbf Off
- lbs Off
- urw Off
- sceri Off
- 17403 Off
- ps Off
- ABD pn Off
- pslm Off
- psdp Off
- pspl Off
- psrf Off
- psnh Off
- psue Off
- psir Off
- pse Off
- psep Off
- psea Off
- psvep Off
- psin Off
- psph Off
- psab Off
- psfin Off
- msor Off
- msfr Off
- msre Off
- msp Off
- mssw Off
- mscon Off
- msat Off
- msad Off
- mscan Off
- msuns Off
- mstp Off
- mswal Off
- msdec Off
- par Off
- msot Off
- mssh Off
- mswe Off
- mswea Off
- mskp Off
- msother Off
- mshe Off
- mspa Off
- msqua Off
- msoth Off
- msnop Off
- psina Off
- pssi Off
- psnap Off
- psinap Off
- psan Off
- psfat Off
- pswit Off
- psdif Off
- psdis Off
- psdep Off
- psanx Off
- psnp Off
- psade Off
- psdisc Off
- mscom Off
- msamp Off
- FL2 Off
- FL3 Off
- FL7 Off
- FL8 Off
- FL9 Off
- FLA-d Off
- FLb Off
- FLg Off
- FLart Off
- FLdiz Off
- FLhead Off
- FLins Off
- FLanx Off
- FLsob Off
- FLpoor Off
- FLprod Off
- FLheart Off
- FLp Off
- FLu Off
- FLv Off
- FLed Off
- FLc Off
- FLf Off
- FL1l Off
- FL1b Off
- FL1d Off
- FL1p Off
- FL1li Off
- FL1lr Off
- FL1lc Off
- FL1f Off
- FL1n Off
- FL4 Off
- FL6 Off
- FL5 Off
- adl o Off
- adl 1 Off
- adl 2 Off
- adl 3 Off
- 1810 0 Off
- 1810 1 Off
- 18102 Off
- 18103 Off
- 19100 Off
- 18200 Off
- 18201 Off
- 18202 Off
- 18203 Off
- FL1 Off
- 1910sg Off
- 1910sgp Off
- 1910sgd Off
- 1111910sgp Off
- 1910sgo Off
- 18302 Off
- 18301 Off
- 18300 Off
- 18304 Off
- 18305 Off
- 18306 Off
- 18400 Off
- 18401 Off
- 18402 Off
- 18403 Off
- 18404 Off
- 1910sgpat Off
- 18901 Off
- 18902 Off
- 18903 Off
- 18904 Off
- 18905 Off
- 1890na Off
- adlr Off
- adlna Off
- adlsn Off
- adlm Off
- adlp Off
- adlot Off
- adlst Off
- 18303 Off
- adlcom Off
- 1845 Off
- 1880 Off
- adl Off
- 1850 Off
- 1860 Off
- 1870 Off
- 1900a Off
- 1900b Off
- 1900d Off
- 1900c Off
- 18900 Off
- 19101 Off
- 19102 Off
- 19103 Off
- 19104 Off
- 19105 Off
- 19106 Off
- 19107 Off
- 19108 Off
- 19109 Off
- 1910aw Off
- 1910bw Off
- 1910cnr Off
- 1910do Off
- alleasp Off
- alleggs Off
- alleib Off
- allesulf Off
- allead Off
- alledm Off
- allelod Off
- allepol Off
- alledust Off
- alleother Off
- 20000 Off
- 2000na Off
- 14D1 Off
- 20001 Off
- 20002 Off
- 2010 Off
- 2002 Off
- 2040a Off
- 2040b Off
- 2020 Off
- 2030 Off
- infpat Off
- picccir Off
- ivadacc Off
- int Off
- fo Off
- fa Off
- ule Off
- infiv Off
- perip Off
- mc Off
- gros Off
- tun Off
- nt Off
- ld Off
- lt Off
- cl Off
- pat Off
- rn Off
- cg Off
- ivocc Off
- ivflu Off
- res Off
- red Off
- allerno Off
- iv-i Off
- adp Off
- adc Off
- adrn Off
- adoth Off
- pia Off
- athe Off
- eiv Off
- biood Off
- mva Off
- pn Off
- infna Off
- infcare Off
- rldna Off
- 2100a Off
- 2100b Off
- 2100c Off
- 2100d Off
- 2100e Off
- 2100f Off
- 2100g Off
- 2110 Off
- asheb Off
- ashmet Off
- asehmop Off
- asprost Off
- asebed Off
- aseshow Off
- asescoot Off
- asehoist Off
- asegrab Off
- asehosp Off
- aselif Off
- asewhee Off
- aseoth Off
- aseneed Off
- aseoxy Off
- asefire Off
- aseph Off
- aseorg Off
- asena Off
- smlasa Off
- pump Off
- smcou Off
- smght Off
- smpup Off
- smrp Off
- smwd Off
- smal Off
- smpco Off
- smpfi Off
- smsa Off
- smpic Off
- smsp Off
- smtsc Off
- smsd Off
- smgip Off
- smgup Off
- smst Off
- smcc Off
- smpes Off
- smep Off
- smms Off
- smcp Off
- smcpat Off
- smcht Off
- smcfsh Off
- smpsbp Off
- smoth Off
- oxgava Off
- oxknosw Off
- prr Off
- shan Off
- adi Off
- epci Off
- apn Off
- cih Off
- pmi Off
- sphic Off
- acihsf Off
- dcdmi Off
- dnr Off
- sac Off
- opnc Off
- msr Off
- hsg Off
- asii Off
- gp Off
- fpp Off
- other Off
- pttv Off
- ottv Off
- sttv Off
- ottvist Off
- oxu Off
- oxupe Off
- oufsp Off
- sh Off
- ih Off
- hd Off
- fab Off
- ug Off
- ir Off
- us Off
- nta Off
- pp Off
- mss Off
- ep Off
- ev Off
- sb Off
- adce Off
- sf Off
- ppf Off
- rma Off
- hsd Off
- ppnf Off
- dfc Off
- fpi Off
- dim Off
- imm Off
- ipp Off
- put Off
- cp Off
- ph Off
- sn Off
- ot Off
- st Off
- aid Off
- oth Off
- mfc Off
- nch Off
- oo Off
- mmc Off
- idt Off
- sse Off
- sdi Off
- ncwdo Off
- ddt Off
- eo Off
- no so-cg Off
- nancg Off
- salin Off
- 2x2 Off
- 4x4 Off
- abd Off
- telf Off
- tap Off
- wg Off
- glov Off
- ns Off
- hyd Off
- ks Off
- td Off
- oint Off
- cs Off
- ther Off
- rb Off
- ic Off
- ivsk Off
- ivp Off
- ivt Off
- as Off
- asi Off
- per Off
- et Off
- cid Off
- ip Off
- ss Off
- duo Off
- bs Off
- abs Off
- m2x11 Off
- mt2 Off
- s4x4 Off
- ng Off
- und Off
- ec Off
- ub Off
- op Off
- ow Off
- sat Off
- fol Off
- ls Off
- sc Off
- tc Off
- aa Off
- otth Off
- app Off
- chem Off
- cta Off
- dcfg Off
- hyt Off
- it Off
- syr Off
- glu Off
- es Off
- ft Off
- srk Off
- strk Off
- sstri Off
- is Off
- stst Off
- ta Off
- vg Off
- kl Off
- sr Off
- bath Off
- can Off
- com Off
- smo Off
- prd Off
- egg Off
- hb Off
- hl Off
- efp Off
- neb Off
- oc Off
- pup Off
- pui Off
- or Off
- inj Off
- ivinf Off
- inh Off
- pcbp Off
- fcc Off
- pe Off
- wcd Off
- pai Off
- doc Off
- soa Off
- injr Off
- pt Off
- sup Off
- atu Off
- qc Off
- sd Off
- cht Off
- mep Off
- ncfa Off
- dpd Off
- wdc Off
- dmc Off
- iad Off
- gc Off
- nmd Off
- trc Off
- oca Off
- fc Off
- pfv Off
- oup Off
- uhm Off
- pmh Off
- eim Off
- e911 Off
- puitc Off
- cpdv Off
- dpdp Off
- rp Off
- ko Off
- ipai Off
- iop Off
- iudp Off
- dc Off
- ds Off
- spe Off
- sfcp Off
- ispm Off
- npp Off
- fi Off
- issi Off
- cqm Off
- idc Off
- msw Off
- iicm Off
- ign Off
- ret Off
- mrw Off
- pcd Off
- dccw Off
- ort Off
- epum Off
- meac Off
- pebp Off
- iap Off
- iiph Off
- iccs Off
- ipc Off
- icdb Off
- ipm Off
- ipap Off
- eiad Off
- ipaot Off
- odit Off
- mepc Off
- ttdp Off
- scwc Off
- mr Off
- dn Off
- cef Off
- pcm Off
- si Off
- spi Off
- eplan Off
- oa Off
- nmbs Off
- tg Off
- idp Off
- ipd Off
- icid Off
- igp Off
- ief Off
- ida Off
- nss Off
- api Off
- aps Off
- pst Off
- sib Off
- sdp Off
- ippph Off
- aperi Off
- pf Off
- ap Off
- apv Off
- pa Off
- ans Off
- imb Off
- imt Off
- ewl Off
- acb Off
- mlc Off
- eob Off
- afs Off
- paa Off
- rt Off
- das Off
- got Off
- lsm Off
- dpc Off
- ils Off
- mpb Off
- iao Off
- ihc Off
- mfs Off
- ipcp Off
- tae Off
- iua Off
- tsb Off
- pc Off
- hc Off
- sp Off
- mdc Off
- oh Off
- tpr Off
- ad Off
- awa Off
- psm Off
- gs Off
- wc Off
- lhk Off
- awpc Off
- errand Off
- nlb Off
- fnc Off
- pric Off
- rsf Off
- src Off
- ebc Off
- ppt Off
- gtwa Off
- ebp Off
- eem Off
- nme Off
- nsf Off
- bmt Off
- thm Off
- tt Off
- ism Off
- ephs Off
- irle Off
- isc Off
- atp Off
- mre Off
- te Off
- pas Off
- sfe Off
- pom Off
- sad Off
- isp Off
- fsm Off
- idy Off
- vdt Off
- ar Off
- noc Off
- ldt Off
- mfa Off
- crm Off
- crp Off
- lrp Off
- mrms Off
- sps Off
- acmr Off
- hwi Off
- hdic Off
- psn Off
- dsdc Off
- usb Off
- dcw Off
- saic Off
- dptw Off
- rsm Off
- kss Off
- uhc Off
- hpa Off
- ipi Off
- grp Off
- ftcm Off
- wac Off
- ria Off
- paf Off
- pafi Off
- pwe Off
- ptc Off
- ges Off
- otp Off
- pwdf Off
- pdaf Off
- pdi Off
- pdis Off
- phas Off
- pep Off
- 12100 Off
- allepen Off
- Patient is not diabetic or is bilateral amputee
- mswref Off
- genitonoprob Off
- Urostomy describe skin around stoma Off
- nutrinoprob Off
- O2prod Off
- woraft Off
- woreve Off
- wormor Off
- worsleep Off
- prodsputcol
- fname Off
- Rehabdc1 Off
- mswgwk1
- stgwk2
- stgwk1
- stgwk3
- rhpoor Off
- Clear Form
- E-mail Form
GENITALIA
No Problem
DischargeDrainage (describe)
Lesions Blisters Masses Cysts Wart
Inflammation Surgical alteration
Prostate problem BPH TURP Date
Self-testicular exam Frequency
Menopause Hysterectomy Date Date last PAP Results
Breast self-exam frequency Discharge RLMastectomy R L Date Other (specify)
(M1700) Cognitive Functioning Patients current (day of assessment)level of alertness orientation comprehension concentration andimmediate memory for simple commands
No Problem
0 - Alertoriented able to focus and shift attention comprehends andrecalls task directions independently
Flatulence
Diarrhea (Frequency)
Constipationimpaction
Hemorrhoids
Last BM
Rectal bleeding1 - Requires prompting (cuing repetition reminders) only under
stressful or unfamiliar conditions
Frequency of stools
Bowel regimeprogram2 - Requires assistance and some direction in specific situations (eg
on all tasks involving shifting of attention) or consistently requireslow stimulus environment due to distractibilityWeeklyLaxativeEnema use Daily Monthly
Other
Diapersother
Ileostomycolostomy site (describe skin around stoma)
No Problem
EliminationOstomy managed by PatientHeadache Location Frequency
OtherAphasia Receptive Expressive
Motor change Fine Gross Site
(M1620) Bowel Incontinence
Dominant side R L (circle)
0 -Very rarely or never has bowel incontinence
Weakness UE LE Location
1 - Less than once weekly
Tremors Fine Gross Paralysis Site
2 - One to three times weekly
Stuporous Hallucinations Visual Auditory (circle)
3 - Four to six times weekly
Hand grips Equal Unequal (specify)
4 - On a daily basis
Strong Weak (specify)Psychotropic drug use (specify)DoseFrequencyOther (specify)
(M1630) Ostomy for Bowel Elimination Does this patient have anostomy for bowel elimination that (within the last 14 days) a) was relatedto an inpatient facility stay or b) necessitated a change in medical ortreatment regimen
(M1710) When Confused (Reported or Observed Within the Last 14 Days)
0 - Patient does not have an ostomy for bowel elimination
0 - Never
1 - Patients ostomy was not related to an inpatient stay and did notnecessitate change in medical or treatment regimen
1 - In new or complex situations only
2 -The ostomy was related to an inpatient stay or did necessitate
2 -On awakening or at night only
change in medical or treatment regimen
3 - During the day and evening but not constantly4 - Constantly
ABDOMEN NA - Patient nonresponsive
No Problem
(M1720) When Anxious (Reported or Observed Within the Last 14 Days)Tenderness Distention Hard Soft AscitesPain (Frequency)
Abdominal girth cm 0 - None of the timeOther 1 - Less often than dailyBowel sounds active absent hypo hyperactive x quadrants 2 - Daily but not constantly
Other3 - All of the time
NA - Patient nonresponsive
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NEURO EMOTIONAL BEHAVIOR STATUS
ELIMINATION STATUS
3 - Requires considerable assistance in routine situations Is not alertand oriented or is unable to shift attention and recall directionsmore than half the time
4 - Totally dependent due to disturbances such as constantdisorientation coma persistent vegetative state or delirium
PERRLA Unequal pupils R L (circle)
5 - More often than once dailyNA - Patient has ostomy for bowel eliminationUK - Unknown
Patient Name Med Record
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NA No Problem
Nasogastric Gastrostomy JejunostomyOther (specify)
Pump (typespecify)Bolus Continuous
Feedings Type (amtrate)Flush Protocol (amtspecify)
SN OtherPerformed by Patient Caregiver
DressingSite care (specify)
Interventions instructionsComments
ENTERAL FEEDINGS - ACCESS DEVICE
Incontinence Urinary Bowel
CaregiverFamily SN
TPNDevice
IV
Following UniversalStandard precautions
Following UniversalStandard precautions
Other (specify)
Migraine Frequency
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NEURO EMOTIONAL BEHAVIOR STATUS (Contd)(M1730) Depression Screening Has the patient been screened for depression using a standardized depression screening tool
0 - No1 - Yes patient was screened using the PHQ-2 scale (instructions for this two-question tool Ask patient Over the last two weeks how often
have you been bothered by any of the following problems)
PHQ-2copy Not at All0-1 Day
Several Days2-6 Days
More Than Halfof the Days7-11 Days
Nearly Every Day12-14 Days
NAUnable toRespond
a) Little interest or pleasure in doing things 0 1 2 3 na
b) Feeling down depressed or hopeless 0 1 2 3 na
2 - Yes with a different standardized assessment and the patient meets criteria for further evaluation for depression3 - Yes patient was screened with a different standardized assessment and the patient does not meet criteria for further evaluation for depression
Copyright Pfizer Inc All rights reserved Reproduced with permission
(M1745) Frequency of Disruptive Behavior Symptoms (Reported orObserved) Any physical verbal or other disruptivedangerous symptomsthat are injurious to self or others or jeopardize personal safety
(M1740) Cognitive behavioral and psychiatric symptoms that aredemonstrated at least once a week (Reported or Observed)
(Mark all that apply)1 - Memory deficit failure to recognize familiar personsplaces 0 - Never
inability to recall events of past 24 hours significant memory lossso that supervision is required 1 - Less than once a month
2 - Once a month2 - Impaired decision -making failure to perform usual ADLs or IADLs 3 - Several times eachinability to appropriately stop activities jeopardizes safety through
actions3 -Verbal disruption yelling threatening excessive profanity
references etc4 - Physical aggression aggressive or combative to self and others
(eg hits self throws objects punches dangerouswith wheelchair or other objects)
5 - Disruptive infantile or socially inappropriate behavior (excludesverbal actions)
6 - Delusional hallucinatory or paranoid behavior7 - None of the above behaviors demonstrated
IMENTAL STATUS Inability to cope with altered health statusillness as evidenced by
1 - Oriented 5 - DisorientedLack of motivation
2 - Comatose Unrealistic expectations3 - Forgetful
Inability to recognize problems 4 - Depressed Denial of problems
ActualPotentialEvidence of abuse neglect exploitationVerbalEmotionalPsychologicalIntervention
FinancialPhysical
PSYCHOSOCIALSENSORY STATUS Describe
Comments
MUSCULOSKELETAL STATUS
Primary language
Learning barrier Mental Psychological Physical Functional Sensory
Unable to readwrite Higher Educational Level
Spiritual CulturalEthnicReligion implications that impact care
No Problem
Explain
Fracture (location)
Swollen painful joints (specify)
Spiritual resourceContractures JointLocation
Phone No Assistive DeviceAtrophySleepRest Adequate Inadequate
Decreased ROM ParesthesiaExplainShuffling Wide-based gait Weakness
Amputation BKAKUE RL (specify)Inappropriate responses to caregiversphysicianclinician staffInappropriate follow-through in pastAngry
ParaplegiaFlat affect
Hemiplegia QuadriplegiaDiscouraged
Other (specify)Withdrawn Difficulty coping DisorganizedDepressed RecentLong term
Treatment
Page 12 of 20
4 - Several times a week 5 - At least daily
(M1750) Is this patient receiving Psychiatric Nursing Services at homeprovided by a qualified psychiatric nurse
0 - No1 - Yes
MENTAL STATUS
6 - Lethargic7 - Agitated
8 - Other
Language barrier Needs interpreter
Patient Name Med Record
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19
Forgetful at times Irritable Anxious Alert
No Problem
English SpanishOther
Deaf Needs American Sing language interpreter
Anxiety RecentLong termTreatment
No Problem
Creole Russian
Sometimes Inadequate
Not hope in recovery
Refuse to follow MD orders
Abandon
PSYCHOLOGICAL STATUS (Contd)
No Problem
Orthopedic cast Removable Permanent for days
Unsteady Gait Transfer ProblemsWheelchair Cane
Walker Other
Orthopedic Protesys Knee Replacement L R Other
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FUNCTIONAL LIMITATIONS ADLIADLs
(M1800) Grooming Current ability to tend safely to personal hygiene7-Ambulationneeds (ie washing face and hands hair care shaving or make up
1 -Amputation
teeth or denture care fingernail care) 2-BowelBladder 8-Speech
0 - Able to groom self unaided with or without the use of assistive(incontinence)
9-Legally blinddevices or adapted methods
3 - Contracture
A -Dyspnea with
1 - Grooming utensils must be placed within reach before able to
4-Hearing
complete grooming activities
B- Other (specify)
5-Paralysis
2 - Someone must assist the patient to groom self
6-Endurance
3 - Patient depends entirely upon someone else for grooming needs
(M1810) Current Ability to Dress Upper Body safely (with or withoutdressing aids) including undergarments pullovers front-opening shirtsand blouses managing zippers buttons and snaps
FALL RISK ASSESSMENT 0 - Able to get clothes out of closets and drawers put them on and
remove them from the upper body without assistance1 - Able to dress upper body without assistance if clothing is laid out
or handed to the patient2 - Someone must help the patient put on upper body clothing3 - Patient depends entirely upon another person to dress the upper
body
(M1830) Bathing Current ability to wash entire body safely Excludes grooming (washing face washing hands and shampooing hair)
1 - With the use of devices is able to bathe self in shower or tubindependently including getting in and out of the tubshower
2 - Able to bathe in shower or tub with the intermittent assistance ofanother person(a) for intermittent supervision or encouragement or reminders
OR(b) to get in and out of the shower or tub OR(c) for washing difficult to reach areas
3 - Able to participate in bathing self in shower or tub but requirespresence of another person throughout the bath for assistance orsupervision
4 - Unable to use the shower or tub but able to bathe selfindependently with or without the use of devices at the sink inchair or on commode
5 - Unable to use the shower or tub but able to participate in bathing
(M1910) Has this patient had a multi-factor Fall Risk Assessment (suchas falls history use of multiple medications mental impairment toiletingfrequency general mobilitytransferring impairment environmentalhazards)
self in bed at the sink in bedside chair or on commode with theassistance or supervision of another person throughout the bath
6 - Unable to participate effectively in bathing and is bathed totally byanother person
0 - No multi-factor falls risk assessment conducted
(M1840) Toilet Transferring Current ability to get to and from the toiletor bedside commode safely and transfer on and off toiletcommode
1 - Yes and it does not indicate a risk for falls2 - Yes and it indicates a risk for falls
0 -Able to get to and from the toilet and transfer independently withor without a device
PlanComments
1 -When reminded assisted or supervised by another person ableto get to and from the toilet and transfer
2 - Unable to get to and from the toilet but is able to use a bedsidecommode (with or without assistance)
3 - Unable to get to and from the toilet or bedside commode but isable to use a bedpanurinal independently
4 - Is totally dependent in toileting
Page 13 of 20
(M1820) Current Ability to Dress Lower Body safely (with or without)dressing aids) including undergarments stacks socks or nylons shoes 0 - Able to obtain put on and remove clothing and shoes without
assistance 1 - Able to dress lower body without assistance if clothing and shoes
are laid out or handed to the patient
2 - Someone must help the patient put on undergarments slackssocks or nylons and shoes
3 - Patient depends entirely upon another person to dress lower body
0 - Able to bathe self in shower or tub independently includinggetting in and our of tubshower
Patient Name Med Record
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18A
Dizziness
Generalized WeaknessArthralgia
InsomniaHeadache
AnxietySOB on exertion
Heartburn
Poor vision
Productive cough
Unsteady GaitPain on ambulation
Varicositis on lower extEdema in __________
Legs weak
Chest pain on exertionFatigues at times
Decreased Bil breath soundsBack Pain
PalpitationsLimited MobilityLimited ROMLeg crampsFreq Coughing episodesNeeds assistance of 1 person
Implement fall precautions for a total score of 10 or greater
Patient Factors Circle appropriate score for each section and total score at bottom (MedQIC) ScoreLevel of Consciousness Mental Status Disoriented X 3 at all times (M1700) 2Level of Consciousness Mental Status Intermittent confusion (M1700 - M1710) 4History of Falls (past 3 months) 1-2 falls (M1032) 2History of Falls (past 3 months) 3 or more falls (M1032) 4Ambulation Elimination Status Chair bound amp requires assist w toileting (M1840) 2Ambulation Elimination Status Ambulatory amp incontinent (M1610 - M1615) 4Vision Status Poor (w or wo glasses) (M1200) 2Vision Status Poor (Legally blind) (M1200)Gait and Balance (Balance problem while standing)Gait and Balance (Balance problem while walking) 1
Gait and Balance (Decreased muscular coordination)
Gait and Balance (Change in gait pattern when walking through doorway) 1Gait and Balance (Jerking or unstable when making turns) 1Gait and Balance (Requires assistance (person furniturewalls or device))
Orthostatic Changes (Droplt20mmHg in BP between lying and standing Increase of cardiac rhythm lt20)
Orthostatic Changes (Drop gt20mmHg in BP between lying and standing Increase of cardiac rhythm gt20)
4
Predisposing Diseases (1-2 present)
Equipment Issues (Oxygen tubing) 1
Total points
4
1
1
2
Medications (Takes 1-2 of these medications currently or win past 7 days)
1
42
Medications (Takes 3-4 of these medications currently or win past 7 days)
Medications (Mark additional point if patient has had a change in these medications or doses in past 5 days) 1
2Predisposing Diseases (3 or more present) 4
Equipment Issues (Inappropriate or client does not consistently use assistive device)
Equipment Issues (Other ) 1
1Equipment Issues (Equipment needs ) 1
Established by the Centers for Medicare amp Medicaid Services (CMS) QualityNet provides healthcare quality improvement news resources and data reporting tools and applications used by healthcare providers and others
Additional service Needed-Impaired Mobility -History of Falls -Predisposing DX - Weakness --Knowledge Deficit or noncompliance with activity restrictions Physical Therapy
Order Obtained
-Unsafe Living Environment -Pt demo unsafe behavior or choices -Limited Resources -At risk and lives alone -Pt is CG for another
Medical Social Services
-ADLIADL Deficits -Sensory Deficits -Decreased Cognition-Unsafe living environment -UE limitations
Occupational Therapy
- - - - - - - -
- - - - - - - -
Certain abilities needed to function independently can be developed or maintained by managing symptoms or through physical or occupational therapy Home health staff needs to evaluate the need for any special assistance devices or equipment and trainpatients on their use If a patient can perform this activity with little assistance they are more independent self-confident and active
If no additional services requested check reasonDiscipline already ordered Pt has been assessed by this discipline win last 30 daysPatientFamily refused additional discipline
QA
(SOC)
SG
No other service approved by Patients Physician
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ADLIADLs (Contd)(M1880) Current Ability to Plan and Prepare Light Meals (eg cerealsandwich) or reheat delivered meals safely
(M1845) Toileting Hygiene Current ability to maintain perineal hygienesafely adjust clothes andor incontinence pads before and after usingtoilet commode bedpan urinal If managing ostomy includes cleaningarea around stoma but not managing equipment
0 - (a) Able to independently plan and prepare all light meals for selfor reheat delivered meals OR
0 - Able to manage toileting hygiene and clothing management (b) Is physically cognitively and mentally able to prepare lightwithout assistance meals on a regular basis but has not routinely performed light
meal preparation in the past (ie prior to this home careadmission)1 - Able to manage toileting hygiene and clothing management
without assistance if suppliesimplements are laid out for the1 - Unable to prepare light meals on a regular basis due to physicalpatient
cognitive or mental limitations2 - Someone must help the patient to maintain toileting hygiene2 - Unable to prepare any light meals or reheat any delivered mealsandor adjust clothing
3 - Patient depends entirely upon another person to maintain toileting(M1890) Ability to Use Telephone Current ability to answer the phonesafely including dialing numbers and effectively using the telephone tocommunicate
hygiene
(M1850) Transferring Current ability to move safely from bed to chairor ability to turn and position self in bed if patient is bedfast 0 - Able to dial numbers and answer calls appropriately and as
desired0 - Able to independently transfer 1 - Able to use a specialty adapted telephone (ie large numbers on
the dial teletype phone for the deaf) and call essential numbers1 -Able to transfer with minimal human assistance or with use of anassistive device 2 - Able to answer the telephone and carry on a normal conversation
but has difficulty with placing calls2 -Able to bear weight and pivot during the transfer process butunable to transfer self 3 - Able to answer the telephone only some of the time or is able to
carry on only a limited conversation3 - Unable to transfer self and is unable to bear weight or pivot when4 - Unable to answer the telephone at all but can listen if assistedtransferred by another person
with equipment4 - Bedfast unable to transfer but is able to turn and position self in5 - Totally unable to use the telephonebed
NA - Patient does not have a telephone5 - Bedfast unable to transfer and is unable to turn and position self
RefusedIndications for Home Health Aide may be needed
(M1860) AmbulationLocomotion Current ability to walk safely oncein a standing position or use a wheelchair once in a seated position ona variety of surfaces
NoYesMD Order obtained
OTSN MSWOther Services ordered STPT
0 - Able to independently walk on even and uneven surfaces and
Comment
negotiate stairs with or without railings (ie needs no humanassistance or assistive device)
1 - With the use of a one-handed device (eg cane single crutchhemi-walker) able to independently walk on even and uneven sur-faces and negotiate stairs with or without railings
2 - Requires use of a two-handed device (eg walker or crutches) to(M1900) Prior Functioning ADLIADL Indicate the patients usualability with everyday activities prior to this current illness exacerbationor injury Check only one box in each row
walk alone on a level surface andor requires human supervisionor assistance to negotiate stairs or steps or uneven surfaces
3 - Able to walk only with the supervision or assistance of another
Functional Area IndependentNeeded
Some HelpDependent
a Self-Care (eg groomingdressing and bathing) 0 1 2
b Ambulation 0 1 2
c Transfer 0 1 2
d Household tasks (eglight meal preparationlaundry shopping)
0
1 2
person at all times
4 - Chairfast unable to ambulate but is able to wheel selfindependently
5 - Chairfast unable to ambulate and is unable to wheel self
6 - Bedfast unable to ambulate or be up in a chair
(M1870) Feeding or Eating Current ability to feed self meals andsnacks safely Note This refers only to the process of eating chewinqand swallowing not preparing the food to be eaten
0 - Able to independently feed self
ACTIVITIES PERMITTED
1 - Able to feed self independently but requires(a) meal set-up OR(b) intermittent assistance or supervision from another person OR(c) a liquid pureed or ground meat diet 8-Crutches1 -Complete bedrest
9-Cane2-BedrestBRP2 -Unable to feed self and must be assisted or supervisedA-Wheelchair3-Up as toleratedthroughout the mealsnackB-Walker4-Transfer bedchair3 - Able to take in nutrients orally and receives supplemental nutrientsC-No restrictions5-Exercises prescribedthrough a nasogastric tube or gastrostomy
D-Other (specify)6-Partial weight bearing4 - Unable to take in nutrients orally and is fed nutrients through anasogastric tube or gastrostomy
7-Independent in home5 - Unable to take in nutrients orally or by tube feeding
Page 14 of 20
Patient Name Med Record
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If the patient experiment-ADLIADL Deficit - Elimination Deficit - Impaired Mobility
18BCMS 485 (POC)
PatientFamily
NA (Home Health Aide Services not needed)
(SOC)
(M1910) See previous page 13 before the FALL RISK ASSESSMENT
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ALLERGIES MEDICATIONS(M2040) Prior Medication Management Indicate the patients usualability with managing oral and injectable medications prior to this currentillness exacerbation or injury Check only one box in each row
None known NKA AspirinSulfaPollens and mold spores
EggsPenicillin
Insect bitesDairyMilk products
Functional Area Independent NeededSome Help Dependent Not
Applicable
a Oralmedications 0 1 2 na
b Injectablemedications 0 1 2 na
Other
MEDICATIONS
(M2000) Drug Regimen Review Does a complete drug regimen reviewindicate potential clinically significant medication issues eg drugreactions ineffective drug therapy side effects drug interactionsduplicate therapy omissions dosage errors or noncompliance
0 - Not assessedreviewed [Go to M2010]
1 - No problems found during review [Go to M2010]
2 - Problems found during reviewNA - Patient is not taking any medications [Go to M2040]
INFUSION IV THERAPYNA
(M2002) Medication Follow-up Was a physician or the physician-designee contacted within one calendar day to resolve clinicallysignificant medication issues including reconciliation
Peripheral line Central line
Typebrand
0 - No
Size
1 -Yes
Non-tunneledGroshong Non-Groshong TunneledInsertion site Insertion date
(M2010) PatientCaregiver High Risk Drug Education Has the patientcaregiver received instruction on special precautions for all high-riskmedications (such as hypoglycemics anticoagulants etc) and how andwhen to report problems that may occur
Lumens DoubleSingle TripleFlush solution
YesPatent N o
0 - No
Injection cap change frequency
1 -Yes
Dressing change frequency
NA - Patient not taking any high risk drugs OR patientcaregiver fullyknowledgeable about special precautions associated with allhigh-risk medications
Sterile CleanPatient RNPerformed by Caregiver Other
Siteskin condition
(M2020) Management of Oral Medications Patients current ability toprepare and take all oral medications reliably and safely includingadministration of the correct dosage at the appropriate timesintervalsExcludes injectable and IV medications (NOTE This refers to abilitynot compliance or willingness)
External catheter lengthOtherComment
0 - Able to independently take the correct oral medication(s) and
PICC Specific
proper dosage(s) at the correct times
Circumference of arm
1 - Able to take medication(s) at the correct times if
X-ray verificationYes No
(a) individual dosages are prepared in advance by another personOR
IVAD Port Specific
(b) another person develops a drug diary or chart
Reservoir DoubleSingle
2 - Able to take medication(s) at the correct times if given reminders
Huber gaugelength
by another person at the appropriate times
NoAccessed Yes date
3 - Unable to take medication unless administered by another person
EpiduralIntrathecal Access
NA - No oral medications prescribed
Siteskin condition
(M2030) Management of Injectable Medications Patients currentability to prepare and take all prescribed injectable medications reliablyand safely including administration of correct dosage at the appropriatetimesintervals Excludes IV medications
Infusion solution (typevolumerate)DressingOtherComment
0 - Able to independently take the correct medication(s) and properdosage(s) at the correct times
1 - Able to take injectable medication(s) at the correct times if
IV-Infusion Medication(s) administered
(a) individual syringes are prepared in advance by another
Drug Name
person OR
RouteDose
(b) another person develops a drug diary or chart
Frequency Duration of therapy
2 - Able to take medication(s) at the correct times if given remindersby another person based on the frequency of the injection
IV-Infusion Medication(s) administered
3 - Unable to take injectable medication unless administered by
Drug Name
another person
Dose Route
NA - No injectable medications prescribed
Frequency Duration of therapy
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17
Patient Name Med Record
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Financial ability to pay for medications Yes No
Was MSW referral made Yes
CommentPlan
Infusion IV Therapy order obtained verified
Gauge Length
Frequency
Iodine
Medline catheter
No
- Unsafe Living Environment -Pt demo unsafe behavior or choices - Limited Resources -At risk and lives alone -Pt is CG for another Yes No
Intravenous IV Port Yes No Flush Ordered Yes NoLast flushed date(vascular access device)
IV Therapy complication observed Pain amp irritation Infiltration amp exravasionOcclusionobstruction fluid overload Other
Dust mitesAnimal dander and urine
(SOC)
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INFUSION IV THERAPY (Contd)
Infusion care provided during visitPump (type specify)OtherCaregiverPatient RNAdministered by
Purpose of Intravenous Access
Pain control
Lab drawsInterventions Instructions Comments Problems DetectedAntibiotic therapy
Maintain venous accessChemotherapyParenteral nutrition (TPN)HydrationOther
CARE MANAGEMENT
(M2100) Types and Sources of Assistance Determine the level of caregiver ability and willingness to provide assistance for the following activitiesif assistance is needed (Check only one box in each row)
Caregiver(s)Caregiver(s) Unclear ifNeed TrainingCaregiver(s) AssistanceNo Assistance Not Likely toCurrently Supportive Caregiver(s) Needed ButType of Assistance Needed in This Provide ProvideServices to Will Provide No Caregiver(s)Area Assistance AssistanceAssistance Provide Available
Assistance
a ADL Assistance (egtransferambulation bathingdressing toileting eatingfeeding)
0 1 2 3 4 5
b IADL Assistance (egmeals housekeepinglaundry telephone shoppingfinances)
0 1 2 3 4 5
c Medication Administration(eg oral inhaled orinjectable)
0 1 2 3 4 5
d Medical ProceduresTreatments (eg changingwound dressing)
0 1 2 3 4 5
e Management of Equipment(includes oxygen IVinfusionequipment enteralparenteralnutrition ventilator therapyequipment or supplies)
0 1 2 3 4 5
f Supervision and Safety(eg due to cognitiveimpairment)
0 1 2 3 4 5
g Advocacy or Facilitation ofpatients participation inappropriate medical care(includes transportation to orfrom appointments)
0 1 2 3 4 5
(M2110) How Often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)1 - At least daily 4 - Received but less than weekly
5 - No assistance received2 - Three or more times per weekUK - Unknown3 - One to two times per week
APPLIANCES SPECIAL EQUIPMENT HOME MEDICAL EQUIPMENT Co
Needs (specify)BraceOrthotics (specify)
Bedside commodeTransfer equipment BoardLift Oxygen HME Co
Prosthesis RUE RLE LUELLEOther HME Rep
Grab bars BathroomOther
PhoneOrganizations providing Home Medical Equipment (HME)
Hospital bed Semi-elec Crank SpecLifeline
Page 16 of 20
Patient Name Med Record
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Ostomy Pliers Shower chair Scooters Hoists
Wheeled Walker Other Phone NA
NA
Removing line date (if know)
Expand intravascular volume
Blood and its derivativesNA
NA
NA
(SOC)
SGFire PreventionSafety Program in place Patient instructed
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SAFETY MEASURES LIVING ARRANGEMENTS SUPPORTIVE ASSISTANCE
Oxygen use NYSigns postedYFollow smoking flammables safety precautions N
Oxygen back-up Knows Instructed how to useAvailable
Oxygen Precautions explained
PlanComments
Safety hazards in the home (check all that apply)NYFire alarmsmoke detector Fire extinguish
Inadequate heating cooling electricity lightingHurricane Disaster Emergency supplieskits
NY
InstructionsInformation Provided Sign Up package (Check all that apply)
Y N
Patient Rights and responsibilities
NYFirst aid boxEmergency Equipment or Supplies
State hotlineABUSE number
NYUnsafe gaselectrical appliances or electrical outlets
Advance directives information
NYInadequate running water plumbing problemsDo not resuscitate (DNR) (if applicable)NUnsafe storage of supplies equipment HME
No telephone available andor unable to use the phonePest problems InsectsrodentsMedications stored safely clearly-easy use check interactions
Service AgreementContractNYOASISHIPAA Privacy Notice ConfidentialityNY
Emergency Plan classification instructionsNYAgency phone numbers addressEmergency planning Exit Plan in place more than one exitClient Information Handbook
Y N
Standard precautions handwashing Infection Control
NYEnough Ventilation
Home safety guidelines
Safe BedsChairs clear pathways
Admission criteria Information for Home visit Services FrequencyY NAble to follow directions in case of Emergency
Diabetes Control other disease management informationNYSlippery Floors Ashtrays (if a smoker)
Fall Prevention Program
NYPlan for power failure emergency lights flashlights etc
THERAPY AND PLAN OF CARE(M2200) Therapy Need in the home health plan of care for the Medicarepayment episode for which this assessment will define a case mixgroup what is the indicated need for therapy visits (total of reasonableand necessary physical occupational and speech-language pathologyvisits combined) (Enter zero [000] if no therapy visits indicated)
) Number of therapy visits indicated (total of physicaloccupational and speech-language pathology combined)
(
NA - Not applicable No case mix group defined by this assessment(M2250) Plan of Care Synopsis (Check only one box in each row) Does the physician-ordered plan of care include the following
PlanIntervention YesNo Not Applicable
a Patient-specific parameters for notifying physician ofchanges in vital signs or other clinical findings 0 1 na
Physician has chosen not to establish patient-specific parameters for this patient Agency will usestandardized clinical guidelines accessible for allcare providers to reference
b Diabetic foot care including monitoring for the presence ofskin lesions on the lower extremities and patientcaregivereducation on proper foot care
0 1 naPatient is not diabetic or is bilateral amputee
c Falls prevention interventions 0 1 na Patient is not assessed to be at risk for falls
d Depression intervention(s) such as medication referral forother treatment or a monitoring plan for current treatment 0 1 na Patient has no diagnosis or symptoms of
depression
e Intervention(s) to monitor and mitigate pain 0 1 na No pain identified
f Intervention(s) to prevent pressure ulcers 0 1 na Patient is not assessed to be at risk for pressureulcers
g Pressure ulcer treatment based on principles of moistwound healing OR order for treatment based on moistwound healing has been requested from physician
0 1 naPatient has no pressure ulcers with need for moistwound healing
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Y
NY
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Patient Name Med Record
HOME ENVIRONMENT SAFETY
NYRelevant medical appliances if applicable ( wheelchair O2 Monitors etc)NYHurricane Shutter Disaster Plan
Medication sheet reconciliatedchecked
Alzheimers Sensory impairments info
Care Plans
Pain Management info Grievance Procedures
Local Resources Guide Mission ownership information
Physical Therapy Total visitsOccupational Therapy Total visits
Speech Therapy Total visitsOther Therapy Total visits
(SOC)
Safety Measures CMS485 (POC)
Cast PrecautionsChange position slowlyCoumadinHeparin PrecautionsDo not lift bend stoopGood handwashing techniqueOxygen PrecautionFire preventionPractice Universal Precautions
15
Safe Ambulation
Respiratory PrecautionsDiabetic PrecautionsWoundDecubitus precautionsAdequate lightingPrevent Cardiac OverloadPrevent Falls and Injuries GI Precautions
Prev Infection ComplicationsSeizure PrecautionsSuicide precautionsSupport due functional limitationTeach coping skillsSafe storagedisposal syringes Cardiac Precautions
GU Precautions
Safe TransfersSAN PrecautionsCatheter CareProvide Emotional SupportEmergency Plan
Maintain Safeclear EnvironmentMaintain Good Skin care
Clear pathways
Other
SG
Correct handwashing technique SG
Check bathroom floorstairs for safety hazardsPsycho-social behavior precautions
SG
SGSG
SG
SG
SG
Other
SG
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PATIENT CARE COORDINATION
CARE PLAN Reviewed with patient involvementOrder obtainedMedication Form completedreviewedupdated No changeMEDICATION RECORD
Ineffective drug therapySignificant drug interactions
Significant side effectsNon-compliance with drug orders Duplicate drug therapy
Other (specify)M S WSNPhysician AidePT OT STCARE COORDINATION
Explain
Yes No
DME SUPPLIES
IV start kit Underpads size BathbenchChemstrips2x2sIV pole
External catheters
Syringes Cane Quad CaneIV tubing
Urinary bagpouch
COTTON TIP APP4x4s
CommodeAlcohol swabs
Ostomy pouch (brand size)
Special mattress overlayABDs
Angiocatheter size
Cotton tipped applicatorsPeroxide Ostomy wafer (brand size)
Pressure relieving device
Wound cleanserExtension tubingsWound gel
Injection caps
Stoma adhesive tape
Eggcrate
Drain sponges Central line dressing
Skin protectant
Hospital bed
GlovesNon-sterile
Side Rails
Infusion pump Hoyer lift
Sterile Batteries size Enteral feeding pump
Hydrocolloids
Enema suppliesSyringes size
Nebulizer
Kerlix size
Feeding tubeNu-gauze
MEFIX 2X11 YD (EA)
Oxygen concentrator
sizetype Suction machine
SalineNSS
FOLEYCATH SUPPLIES
Suture removal kit Ventilator
Tape
Fr catheter kit
Staple removal kit Walker
(tray bag foley)Transparent dressings
Steri strips
Straight catheter
Wheelchair
Ointment
TRIPLE ANTIBIOTIC 30GR
Irrigation tray
Tens unitSalineNSS
OtherAcetic acid
Other
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Patient Name Med Record
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PATIENTCAREGIVER INSTRUCTIONS-TEACHINGCheck all that appliesPatientcaregiver(CG) independent with
Trach care
N oYesWoundDecubitus care
Yes No
Yes N o
Ostomy care Yes
N oYesDiabetic managementcare
N o
N oYesNoYesInsulin administration N oYes
Oxygen useprecautions
Yes N oGlucometer usecalibration N oYes
Use of home medical equipmentdevices
N oYesNutritional managementDiet
NoCaregiver present during the visit Yes
PatientCG educationteaching this visit for
N oYesPatientCG able to understand instructionsteaching
Does the patientCG have a plan when disease symptoms exacerbate (eg when to call the nurseAgency vs emergency 911) N oYes
Comment(s)
SKILLED CARE PROVIDED THIS VISIT
Medication management Administration Oral Injection IV-Infused Inhaled
Foley care Yes N o
Pain ManagementHome prescribed exercisesActivities of Daily LivingPersonal Care
MEDICATION
DISEASE PROCESS COMPLICATIONSSS OFILEAL CONDUITOSTOMY SKINFOOT CAREDIET FLUIDS INFECTION CONTROL
OTHER INSTRUCTIONS GIVEN
N oYesElimination Incontinence management
NEEDS FURTHER TEACHINGExplain
NA NANANANANA
NANANANANANANA
Yes N oPhysician follow up visitsappointments NA
Expected Outcome
DISCHARGE PLANNING DISCUSSEDEXPLAINED Patient unable to perform own Wound Care dueto
Patient unable to InsulineInjection self administration dueto
No SO or CG ablewilling for wound careInsulin-Injection administration at this time
Telfa
Colostomy Supplies
Thermometer
Texas Cath
Red Box (Biohazard)
Betadine Solution
Abd Pads
Duoderm
Sharp Container
Ace band size
Leg Straps Cath
ALCOHOL PREP PADS
DUODERM CFGHY-TAPE 2INSERTION TRAY 5CC
INSULIN SYRINGE ____ CCSYRINGES
Glucometer
MICROPORE TAPE 2
SOFTWICK 4X4
VASELINE GAUZE 3X9
KLING 4
(SOC)
Medication Management Check all that appliesidentified Potential adverse effectsdrug reactionsSG
Skil led Observation AssessmentINJECTION ROUTE_______ SITE _____ MED GIVEN ______________________ DOSE __________ REACTION _____________________________
Foley ChangeCare Patient Educationteaching Wound Care Dressing Change Prep Admin Insulin
StandardUniversal Precautions Followed Aseptic Tech Used Quality Control of Glucometer Performed Sharps Discarded Inside Sharps Container
ProcedureTx welltolerated by Pt
Diabetic Observation Care
Correct handwashing technique followed SG ManagementEvaluation Patients Care Plan No caregiverfamily availablewilling to help patient with care procedures
SG
Pshycological carebehaviour problems prevention NA
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Orders by discipline (optional) To complete CMS485 (POC)
SN - ORDERS - FREQUENCYDURATION
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Patient Name Med Record
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21
OTHER
General
Psychiatric
F o l e y Care
REPORT ANY ELEVATIONS IN TEMPERATURE TO THE MD
Wound CareDecubitus
IMPROVE THE PTS ABILITY TO PREVENT OR COPE WITH BREATHING DIFFICULTIES
Asthma Respiratory
INST FOR SS EASY FATIGABILITY DYSPNEA PALPITATIONS ANGINA TACHYCARDIAPALLOR DIZZINESS JAUNDICE AND FEVER INST FOR G I DISTURBANCES ASSESS FOR CENTRALNERVOUS SYSTEM SYMPTOMATOLOGY OBTAIN APPROPRIATE LAB TESTS AND REPORT FINDINGS TO MD ADMINISTER PRESCRIBED INJECTABLE _________________ USING ______ TECHNIQUE
Anemia
Included as reference only your Professional Staff must reviewupdatepersonalizedapprove the orders
INSTRUCT IN PREPARATION amp ADMINISTRATION OF INSULIN INSTRUCT ONSET PEAK ampDURATION OF ACTION OF INSULIN INSTRUCT PROPER DISPOSAL OF SYRINGESNEEDLES NURSE TO MONITOR BLOOD SUGAR WITH GLUCOMETER OR ___________ON __________FREQUENCY ampNOTIFY MD OF ALTERED RESULTS TEACH GLUCOMETER OR __________ PROCEDURE amp INTERPRETING RESULTS
InsulinGlucometer
INST DISEASE PROCESS amp COMMON COMPLICATIONS INST PRESCRIBED DIET amp SHOPPING ADVICE INST SSHYPOHYPERGLYCEMIA amp EMERGENCY PROCEDURES INST GOOD SKIN CARE amp GOOD FOOT CARE DAILY CARE OFTEETH INST DIABETIC CHART INST SampA TESTING amp READING RESULTS INSTRUCT TO CARRY ID THAT INCLUDESINFORMATION REGARDING DIABETIC STATUS NAMES amp DOSAGE OF MEDS amp ACTION TO TAKE IF INSULIN REACTION OCCURS INST IMPORTANCE OF GOOD PERSONAL HEALTH HABITS INCLUDING EXERCISE ADEQUATEREST SLEEP REGULAR MED CHECK-UPS (INCLUDING PODIATRIC OPTHAMOLOGIST amp DENTIST)
DiabetesMellitus
INST PACED ACTIVITY PROGRAM
OBSERVE FOR SS OF DECOMPENSATION SUCH AS INCREASING TACHYCARDIA WSUDDEN ONSET SOB ON MINEXERTION ORTHOPNEA EXTREME ANXIETY PROGRESSIVE CYANOSIS GENERALIZED PALLOR AND DIAPHORESISCHF
INSTRUCT PROPER ADMINISTRATION OF OXYGEN THERAPY INSTRUCT OXYGEN PRECAUTIONSINSTRUCT MAINTENANCE OXYGEN EQUIPMENTOxygen
ASSESS FOR CHEST PAIN TYPE LOCATION INTENSITY DURATION amp FREQUENCY IS PAINMANAGEMENT NOTIFY MD IF PAIN PERSISTS IS GRADUAL PROGRESS ACTIVITY INCREASEINST DISCONTINUE ACTIVITY IF CHEST PAIN DYSPNEA FATIGUE OR PALPITATIONS OCCUR
Angina
PSYCHOLOGICAL ASSESSMENT ASSESS NEUROLOGICAL STATUS IMPLEMENT AND MONITOR BOWEL REGIMEN ampTEACH PROGRAM TO FAMILY SN TO MONITOR TRANQUILIZER EFFECTS GIVEN FOR SEVERE AGITATIONANXIETYEVALUATE FOR WEIGHT LOSS WEIGH PATIENT Q VISIT AND RECORDS WEIGHTS MONITOR LEVEL OFCONSCIOUSNESS ASSESS COORDINATION AND BALANCE PROVIDE EMOTIONAL SUPPORT TO PATIENT ANDFAMILY OBSERVATION AND EVALUATION OF BLADDER ELIMINATION HABITS MANAGEMENT IF INCONTINENCEASSIST FAMILY IN SETTING UP ROUTINE PATIENT-CENTERED AND STRESS THE IMPORTANCE OF ADHERING
Alzheimers
AIDE - ORDERS - FREQUENCYDURATIONTUBSHOWER BATH PERSONAL CARE HAIR COMB SHAMPOO PRN MOUTHDENTURE CARE SKIN CHECK ORAL HYGIENE TPRASSIST TO DRESS ASSIST WITH AMBULATION PREPARE SERVE MEALS GROCERY SHOP WASH CLOTHES LIGHT HOUSEKEEPING ASSIST WITH PERSONAL CARE AND ADLSERRANDS NOTIFY LAST BM IF NONE FOR 3 DAYS FEETNAILS CARE PERI CARE REPORT SIGNIFICANT FINDING TO SN STRAIGHTEN ROOM amp CHANGE LINEN
PT - ORDERS - FREQUENCYDURATIONEVALUATE BALANCE AND COORDINATION EVALUATE ENDURANCE MOBILITY NEUROMUSCULAR RE-EDUCATIONPERFORM PRESCRIBED THERAPEUTIC EXERCISES NOTIFY SIGNIFICANT FINDING TO MDAGENCY BED MOBILITY TRAININGGAIT TRAINING WITH ASSISTIVE DEVICE TEACH HOME MAINTENANCE PROGRAM AND STRENGTHENING EXERCISEEXERCISE BOTH PASSIVE AND ACTIVE EXERCISE REGIMEN TRANSFER TRAINING INSTRUCT IN SAFETY MEASURES FALL PRECAUTIONS
OT - ORDERS - FREQUENCYDURATIONEVALUATE PATIENT AND HOME FOR SAFETY ADL TRAINING PROGRAM MUSCLE RE-EDUCATION BODY IMAGE TRAININGINCREASE RIGHT AND LEFT UPPER EXTREMITIES STRENGTH THERAPEUTIC EXERCISE TO (R) AND (L) HANDINCREASE STRENGTH AND COORDINATION PROPRIOCEPTION AND SENSATION
ST FOR EVALUATION TO PROVIDE ORAL MOTOR EXERCISES INVOLVING LINGUAL AND LABIAL EXERCISES SPEECH ARTICULATION DISORDER TREATMENTIMPROVE SPEECH FACIAL SYMMETRY AND MUSCULATION IMPROVE DYSPHAGIA VOICE DISORDER TREATMENT AURAL REHABILITATION NON-ORAL COMMUNICATION LANGUAGE DISORDER TREATMENT
ST - ORDERS - FREQUENCYDURATION
MSW - ORDERS - FREQUENCYDURATIONMSW FOR ASSESSMENT OF SOCIAL AND EMOTIONAL FACTORS COMMUNITY RESOURCE PLANNINGCOUNSELING REGARDING MANAGEMENTADJUSTMENT TO ILLNESS LONG RANGE PLANNING AND DECISION MAKING
PROVIDE SUPPORTIVE AND RELAXATION THERAPY PROVIDE FAMILY THERAPY ASSESS INTERPERSONALBEHAVIOR ASSIST PATIENT TO DEFINE PROBLEMS amp SOCIAL RELATIONSHIPS GIVE POSITIVE REINFORCEMENTASSIST PATIENT TO VERBALIZE FEELINGS
Anxie ty
INST DISEASE PROCESS AND COMMON COMPLICATIONS INST LOW SODIUM DIET - STRESSING IMPORTANCE OFADHERENCE MONITOR PATIENTS BLOOD PRESSURE CLOSELY AND NOTIFY MD OF ANY SIGNIFICANT CHANGESINSTRUCT PT TO AVOID OVER-THE-COUNTER COLD AND SINUS MEDS AS THEY CONTAIN VASOCONSTRICTORINST OF HYPERTENSIVE CRISIS MONITOR FOR SS OF ORTHOSTATIC HYPOTENSION
Hypertension
ASSESS PSYCHOLOGICAL STATUS PROVIDE SUPPORTIVE THERAPY PROVIDE REMOTIVATION ASSESSINTERPERSONAL BEHAVIOR ASSIST PATIENT TO DEFINE PROBLEMS amp SOCIAL RELATIONSHIPS GIVE POSITIVEREINFORCEMENT ENCOURAGE PATIENT TO PERFORM PERSONAL HYGIENE amp GROOMING ACTIVITIESASSIST PATIENT TO EXPRESS REALISTIC IDEAS amp PLANS ASSIST PATIENT TO VERBALIZE FEELINGS
Depression
INSTRUCT PATIENT IN CONSEQUENT PHYSICAL L IMITATIONS PLANNING AN ADEQUATE LEVEL OF DAILYACTIVITIES TEACH PT RE ARTHRITIS SS OF EXACERBATION TEACH THE IMPORTANCE OF GOOD POSTUREPREVENT TRAUMA TO JOINTS INST PT IN THE USE OF ASSISTIVE DEVICE AS PRESCRIBED
Osteoarthritis
SKILLED OBSERVATIONEVALUATION ASSESS VITAL SINGS amp SS COMPLICATIONSINSTRUCTEVALUATE UNDERSTANDING OF DISEASE PROCESS DETECTING COMPLICATIONSDIETNUTRITIONAL STATUS SAFETY PRECAUTIONEMERGENCY MEASURES MED-REGIMEN
PSYCH ASSESSMENT ASSESS FOR SS OF EPSDETECT AND ALLEVIATE SOMATIZED COMPLAINTSLIMIT SETTING MOTIVATION TECHNIQUES IMAGERY TECHNIQUES
RELAXATION TECHNIQUESGOAL ORIENTED TASKS
FOLEY INSERTION _______FR FOLEY WITH___________cc BALLONCHANGE Q MONTH amp PRN x3 FOR CLOGGED LEAKING OR ACCIDENTAL REMOVALINST DRESSING CHANGES ________________________ MONITOR FOR SS COMPLICATIONS amp NOTIFY MD
INST SS INFECTION
MONITOR STATUS OF WOUND OR DECUBITUS (place) ______________INST INFECTION CONTROL MEASURES
INST GOOD NUTRITION TO FACILITATE HEALINGMEASURE AND RECORD WOUND or DECUBITUS SIZE AT SOC AND AT LEAST WEEKLY THEREAFTEROPEN WOUND CAREDRESSING CLEANSE WOUND WITH ___________ TO RINSE WITH __________ AND APPLY______________ AND PRN
OBSERVE AND RECORD TYPE AND AMOUNT OF DRAINAGE COLOR INFECTION SWELLING REDNESS PAINDE CUB ITUS CAR EDR ESS ING CLEAN SE W OUN D WITH ___________ TO R IN SE WITH __________ AN D APP LY ______________ AN D PR N
TEACH THE PATIENT HOW TO USE A METERED-DOSE INHALER MAINTAIN EFFECTIVE AIRWAY CLEARANCE
EMPHASIZE THE IMPORTANCE OF ADEQUATE DAILY FLUID INTAKE
PROMOTE AN EFFICIENT BREATHING PATTER
INST INFECTION CONTROL amp PULMONARY HYGIENE INST COMPLICATIONS IN CARDIOPULMONARY STATUSINST PREVENTION OF COMPLICATIONS IE AVOID OVER-EXERTION CHILLING CROWDS ETC
INST D ISEASE PROCESS amp MAINTENANCE
INSTRUCT COUGHING DEEP BREATHING EXERCISES INST PATIENT TO MAINTAIN ADEQUATE REST PATTERN
MANAGEMENT AND EVALUATION OF A PATIENT CARE PLAN TEACHING AND TRAINING DISEASE PROCESS SKIN CARE WOUND CAREDRESSING CHANGE DECUBITUS CARE MEDICATION REGIMEN DIETNUTRITIONHYDRATION COMPLICATIONS OF ENT FEEDING AS INDICATED
PAIN CONTROL MEASURES SYMPTOM CONTROL MEASURES SINGSSYMPTOMS OF INFECTION SAFETYPREVENTION OF INJURY EMERGENCY PLANS OXYGEN ADMINISTRATION
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GOALSREHABILITATION POTENTIAL CMS485 (POC)Included as reference only your Professional Staff must reviewupdatepersonalizeapprove the goals
DISCHARGE PLANNING DISCUSSED WITH PATIENT Yes No REHAB POTENTIAL ExcellentPoor Fair Good
SIGNATUREDATES
X DateStaff Completing the OASIS (signaturetitle)
OASIS INFORMATION
Data Entry Date amp Locked Date SubmittedQA Date Reviewed
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SN - GOALSMRMS _________________ WILL EXHIBIT VITAL SIGNS WITHIN ACCEPTABLE RANGE AND STABILIZED DISEASE PROCESSVERBALIZES KNOWLEDGE OF DISEASE MANAGEMENT MEDICATIONS SIDE EFFECTS PRECAUTIONS DIET FLUIDS TREATMENT PROGRAM SS NECESSITATING MEDICAL ATTENTION EMERGENCY CARE
STABILIZATION OF PSYCHOLOGICAL STATUS WITHIN DISEASE LIMITS TO REDUCE THE PATIENTS ANXIETY LEVELDEPRESIONANXIETY CONTROLED TROUGH MED REGIMEN INTERVENTIONS
ANEMIA CONTROLLED THROUGH MED REGIMEN IMPROVED HEMATOLOGIC STATUS
General
Psychiatric
A n e m i aHEALED WOUND WITHOUT INFECTION OR COMPLICATIONS DEMONSTRATE PROPER WOUND CARE
Wound Care
PTSO SHOULD UNDERSTAND THE NATURE SYMPTOMS STAGE AND PROGRESSION OF ALZHEIMERS DISEASEKNOW HOW TO RECOGNIZE PTS OWN STRESS AND WAYS TO PREVENT OR REDUCE IT PROMOTE SOCIAL INTERACTION AS TOLERATED BY THE PATIENT
Decubitus
DEMONSTRATE STRATEGIES TO BE USED DURING A COUGHING EPISODE HELP THE PATIENT IDENTIFY FACTORSTHAT MAY CAUSE ASTHMA ATTACKS OR CONTRIBUTE TO THEMAsthma
SAFELY ADMINISTERS INJECTION COMPREHEND RATIONALE FOR AND IS ABLE TO ROTATE INJECTION SITESCOMPREHEND SAFETY FACTORS IN SYRINGENEEDLE DISPOSALPATIENTCG ABLE TO MONITOR BLOOD SUGAR CORRECTLY WITHOUT ASSISTANCEABLE TO NOTIFY MD OF ALTEREDOUT OF RANGE RESULTS
InsulinGlucometer
DISCHARGE PT WHEN BLOOD SUGARS ARE WITHIN THE NORMAL FOR PATIENT RANGEKNOW THE ACCEPTABLE RANGE FOR BLOOD SUGAR LEVEL COMPLY WITH DIET RESTRICTIONS Diabetes
MellitusRETURN TO SELF-MANAGEMENT OF HEALED FRACTURED
FractureKNOW ABOUT SIGNS SYMPTOMS AND PRECIPITATING CAUSES OF CHF KNOW HOW TO TAKE THE PULSE AND KNOWTO CONSULT THE DOCTOR BEFORE CONTINUING MEDICATION IF THE PULSE RHYTHM CHANGES KNOW TOA V O I D S M O K I N G A N D S M O K Y E N V I R O N M E N T S A N D P E R S O N S W I T H I N F E C T I O N S E S P E C I A L L Y R E S P I R A T O R Y I N F E C T I O N S
CHF
UNDERSTAND THAT HYPERTENSION IS A CHRONIC DISEASE REQUIRING LIFE LONG TREATMENT EXHIBIT BLOODPRESSURE READINGS CONSISTENTLY WITHIN NORMAL OR SPECIFIED RANGE DEMONSTRATE ADHERENCE TO ALOW-SALT LOW-FAT DIET
Hypertension
HELP THE PATIENT ACHIEVE PAIN RELIEVE AND REDUCE ANGINA EPISODES UNDERSTAND THE CAUSE OFANGINA PECTORIS AND POSSIBLE PRECIPITATING FACTORS FOR AN ATTACK IDENTIFY PERSONAL STRESSORSTHAT MAY CONTRIBUTE TO THE PROBLEM AND BEGIN ELIMINATING OR MINIMIZING THEM KNOW WAYS TOREDUCE THE FREQUENCY OF ANGINA EPISODES
Angina
HEALED DECUBITUS WITHOUT INFECTION OR COMPLICATIONS DEMONSTRATE PROPER DECUBITUS CARE
Alzheimers
UNDERSTAND SS OF BRONCHITIS OR OTHER RESPIRATORY INFECTION AND DISEASE EXACERBATIONUNDERSTAND THE DANGERS OF SMOKING AIR AND CHEMICAL POLLUTANTS AND RESPIRATORY INFECTIONUNDERSTAND AND PRACTICE COUGHING AND DEEP-BREATHING EXERCISES
Respiratory
DAILY COMPLIANCE WCATHETER CARE DECREASE RISK OF URINARY INFECTIONCatheter
INCREASED PAIN RELIEF INCREASED STRENGTH AND ENDURANCE COMPREHEND AND DEMONSTRATE HOME EXERCISEOsteoarthritis
AIDE - GOALS
GAIT PATTERN ENDURANCE STRENGTH AND BALANCE WILL IMPROVE AND PATIENT WILL DEMONSTRATECORRECT BODY MECHANICS WIN 4-6 WKS PTCG WILL COMPREHEND AND DEMONSTRATE HOME EXERCISEPROGRAM WITHIN 4-6 WKS
FAIR-TO BE ABLE TO CARRY OUT MINIMAL ADLS WITH AVAILABLE HOME SUPPORTWILL NOT BE ABLE TO CARRY OUT ADLS WITHOUT MAXIMUM SUPPORT
RETURN TO INDEPENDENT AMBULATION BE SAFE IN SELF CAREPATIENT WILL BE ABLE TO FUNCTION WITH ASSISTANCE OF CAREGIVERWITHIN HESHE CURRENT LIMITATIONS AT HOME
PATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HISHER CURRENT LIMITATIONS AT HOME
PT - GOALS
GOOD RETURN TO PREVIOUS LEVEL OF ADLS INDEPENDENTLY
GAIT PATTERN ENDURANCE STRENGTH AND BALANCE WILL IMPROVE AND PT WILL DEMONSTRATECORRECT BODY MECHANICS WITHIN _____ WEEKS
PATIENT WILL EXPERIENCE A DECREASE IN PAIN
PTCG WILL COMPREHEND AND DEMONSTRATE HOME EXERCISEPROGRAM WITHIN _____ WEEKS
OT PATIENT WILL EXHIBIT IMPROVEMENT IN COPING IN ADLSIADLS MUSCLE USEMOTORCOORDINATIONNEURO RESPONSEUSE OF ORTHOTIC SPLINTING ANDOR EQUIPMENT
OT - GOALS
PATIENT WILL DEMONSTRATE FUNCTIONAL COMMUNICATIONS EXHIBIT MAXIMUM VERBAL AND SENTENCEFORMULATION AND COMPREHENSION WITHIN DISEASE LIMITS WITHIN _____ WEEKS
ST - GOALS
PATIENT WILL DEMONSTRATE APPROPRIATE USE OF FUNCTIONAL VERBALNON-VERBALCOMMUNICATIONS SYSTEMS WITHIN _____ WEEKS
PATIENT WILL DEMONSTRATE IMPROVED READINGWRITING USE OF GESTURESNUMBERS WITHIN _____ WEEKS
PATIENT WILL DEMONSTRATE IMPROVED SWALLOWINGCHEWINGORALMOTOR CONTROL WITHIN _____ WEEKS
PATIENT WILL HAVE ADEQUATE SUPPORT TO REMAIN IN HOME WITH ASSISTANCE OF COMMUNITYRESOURCES FOR FINANCIAL TRANSPORTATION AND PERSONAL CARE ASSISTANCE WITHIN _____ WEEKS
MSW - GOALSPSYCHOSOCIAL EVALUATION WILL BE PERFORMED PTCG WILL BE COUNSELED REGARDING MANAGEMENTamp ADJUSTMENT TO ILLNESS LONG TERM PLANNING AND DECISION MAKING APPROPRIATE COMMUNITYRESOURCE REFERRALS WILL BE MADE
WILL DISCHARGE THE PATIENT WITHIN 60 DAYS WHEN PATIENT ANDORCAREGIVER ISARE ABLE TO DEMONSTRATE KNOWLEDGE OF DISEASE MANAGEMENT SS COMPLICATIONSPATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HISHER CURRENT LIMITATION AT HOME
ABLE TO REMAIN IN HOMERESIDENCEALF WITH ASSISTANCE OF PRIMARY CAEGIVERSUPPORT AT HOMEABLE TO UNDERSTAND MEDICATION REGIMEN AND CARE RELATED TO HISHER DISEASEWILL BE DISCHARGE WHEN MAXIMUM FUNCTIONAL POTENTIAL REACHED
Patient Name Med Record
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XPatient Signature if required optional if itinerary is used
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- OASIS_C_SOC
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- PT ID PERFORMED VIA NAME DOB FACE RECOGNITION AND ADDRESS BEFORE SERVICE PROVIDED Off
- TIME IN
- TIME OUT
- Agency Name SALUD HOME CARE INC
- Phone 305-555-5555
- Employees NameTitle Completing the OASIS
- who has signed the plan of care
- Physician name
- Address 1
- Address 2
- Phone Number
- Address 1_2
- Address 2_2
- Patient Phone
- Reason
- Name
- Other Physician if any
- Phone_2
- Address 1_3
- Address 2_3
- Phone Number_2
- REFERRAL SOURCE if not from Primary Physician
- undefined_6
- Phone_3
- Fax
- Evacuation Form needed Emergency Reg 1
- Evacuation Form needed Emergency Reg 2
- EMERGENCY CONTACT
- Address
- Comments 1
- Comments 2
- Phone_4
- Relationship
- OTHER
- Comment 1
- Comment 2
- 11 Other specify
- a
- b
- 7 Other specify
- c
- d
- e
- f
- a_2
- b_2
- d_2
- e_2
- f_2
- a_3
- b_3
- d_3
- Comment if needed 1
- Comment if needed 2
- a_4
- a_5
- a_6
- Date 23
- undefined_7
- undefined_8
- b_4
- b_5
- b_6
- Date_2
- undefined_9
- undefined_10
- Date_3
- undefined_11
- undefined_12
- d_4
- d_5
- d_6
- Date_4
- undefined_13
- undefined_14
- Date_5
- undefined_15
- undefined_16
- Date_6
- undefined_17
- undefined_18
- 12 1
- 12 2
- Date_7
- undefined_19
- undefined_20
- Date_8
- undefined_21
- undefined_22
- MAIN REASON FOR HOME HEALTH CARE 1
- MAIN REASON FOR HOME HEALTH CARE 2
- Fractures site
- Surgeries site
- Cancer site
- Open Wound site
- Decubitus site
- Other specify
- Other
- Pending or Needed
- Yes Number of times
- Reason s Dates
- MobilityAmbulatory devices used
- Other specify_2
- undefined_23
- Comments if needed 1
- Comments if needed 2
- Comments if needed 3
- Comments if needed 4
- undefined_24
- Name_2
- Phone number if different from patient
- Relationshiphealth statusability to help 2
- Any paid help explain
- Specify 1
- Specify 2
- Specify 3
- Any ears surgeryprocedure
- Date_9
- Otherspecify 1
- Otherspecify 2
- Other agencies involved in care 1
- Other agencies involved in care 2
- 1
- 2
- Other_2
- Infections
- Cataract surgery Site
- Date_10
- Other eyes surgery Site
- Date_11
- explain 1
- explain 2
- Any nose surgery
- Date_12
- Other specify_3
- 1_2
- 2_2
- MassesTumors site
- Lesions explain
- Any surgeryprocedure
- Other specify 1
- Other specify 2
- Other specify 3
- Date_13
- Other specify_4
- No Problem
- Medication
- Other_3
- Pain control treatmentmeds Side effect mark
- Other_4
- Is there a regular pattern to the pain explain
- Other_5
- Comment
- What was the outcome
- Type II OnsetExacerbation date
- DietOral control specify
- INSULIN dosage frequency scale explain
- 1_3
- 2_3
- Since
- Other_6
- A1c
- BS
- mgdL DateTime
- Blood sugar ranges
- site 1Location site
- site 2Location site
- site 3Location site
- Frequency
- Other_7
- site 1New Onset Exacerbation
- site 2New Onset Exacerbation
- site 3New Onset Exacerbation
- Able to use Glucometer
- site 1Present level 010
- site 2Present level 010
- site 3Present level 010
- Diabetes Management Problems explain 1
- Diabetes Management Problems explain 2
- Other Endocrine problems
- site 1Occasional y Cont Intermittent Frequency Frequently
- site 2Occasional y Cont Intermittent Frequency Frequently
- site 3Occasional y Cont Intermittent Frequency Frequently
- site 1Pain type ach ng burn ng rad ating neura gia etc
- site 2Pain type ach ng burn ng rad ating neura gia etc
- site 3Pain type ach ng burn ng rad ating neura gia etc
- Anemia specify type if known
- site 1Feeling of pain internal external acute chronic
- site 2Feeling of pain internal external acute chronic
- site 3Feeling of pain internal external acute chronic
- site 1Pain is worse morning
- site 2Pain is worse morning
- site 3Pain is worse morning
- Immunodeficiency problems explain
- Other 1
- Other 2
- Other_8
- explain 1_2
- explain 2_2
- explain 3
- explain 4
- Other specify 1_2
- Other specify 2_2
- undefined_25
- undefined_26
- undefined_27
- undefined_28
- undefined_29
- undefined_30
- undefined_31
- undefined_32
- undefined_33
- undefined_34
- undefined_35
- undefined_36
- M1310 Pressure Ulcer Length Longest length headtotoe
- undefined_37
- cm
- greatest width perpendicular to the length
- M1314 Pressure Ulcer Depth Depth of the same pressure ulcer from
- cm_2
- visible surface to the deepest area
- undefined_38
- cm_3
- 1_4
- 2_4
- 3_2
- Other_9
- 4_2
- Caregiver name
- Other_10
- cant integument findings
- Observation
- Observation_2
- Caregiver name_2
- Other_11
- Wound cleaned with specify
- Wound irrigated with specify
- 1 Size
- cm width
- Wound packed with specify
- Location
- Other_12
- Wound dressingcover applied specify
- 2 Size
- cm width_2
- Comments 1_2
- Comments 2_2
- Location_2
- Other_13
- Sizecm LengthxWidthxDepth
- Sizecm LengthxWidthxDepth_2
- Diagram 4Sizecm LengthxWidthxDepth
- Tunneling Undermining cm
- Tunneling Undermining cm_2
- Diagram 4Tunneling Undermining cm
- Stage IIIIIIIV pressure uIcers only
- Diagram 4Stage IIIIIIIV pressure uIcers only
- Odor Fool normal etc
- Diagram 4Odor Fool normal etc
- Edema pedal sacral p tting etc
- Diagram 4Edema pedal sacral p tting etc
- Appearance of the Wound Bed
- Diagram 4Appearance of the Wound Bed
- Treatment Ordered
- Diagram 4Treatment Ordered
- Other_14
- Other_15
- Other_16
- Other_17
- Yes 1
- Yes 2
- Yes 3
- Height
- Weight
- Radiating to
- GainLoss
- lb X
- Frequencyduration
- Sittinglying R
- L
- Standing R
- L_2
- Medication_2
- Temperature
- Other_18
- Apical
- Brachial
- Radial
- Carotid
- Dependent
- Pitting 1234
- Respirations
- Site
- Cramps site
- Disease Management Problems explain
- Right Upper
- Right
- Right Lower
- 1_5
- 2_6
- 3_3
- Left
- Left Upper
- Left Lower
- Pacemaker Date
- Last date checked
- SOB on minimal effortwalk
- Type
- fy
- Other Prob 1
- Other Prob 2
- O2
- Trach sizetype
- CaregiverfamilyOther
- Yes explain 1
- Yes explain 2
- Other_19
- Comments 1_3
- Comments 2_3
- Increase fluids
- Restrict fluids
- Frequency_2
- Amount
- Yes describe 1
- Yes describe 2
- Frequency_3
- Other 1_2
- Other 2_2
- Nocturia x
- Bowel Off
- undefined_52
- Diapersother
- Other_20
- No
- 2TOTAL
- Urinary Catheter Type
- Last changed on
- Foley inserted date
- with
- Inflated balloon with
- Irrigation solution Type specify
- Amount_2
- mL Frequency
- Returns
- No_2
- 1_6
- 2_7
- Describe at risk intervention and plan 1
- Describe at risk intervention and plan 2
- Describe at risk intervention and plan 3
- DischargeDrainage describe
- Lesions
- Blisters
- Masses
- Cysts
- Wart
- Other specify_5
- Surgical alteration
- Prostate problem BPH TURP Date
- undefined_53
- undefined_54
- Selftesticular exam Frequency
- Hysterectomy Date
- undefined_55
- undefined_56
- Date last PAP
- undefined_57
- undefined_58
- Results
- Breast selfexam frequency
- Mastectomy R L Date
- undefined_59
- undefined_60
- Other specify_6
- Last BM
- Diarrhea Frequency
- Bowel regimeprogram
- Incontinence Off
- Urinary Off
- Diapersother_2
- Other_21
- te describe skin around stoma
- Ileostomycolostomy s 2
- Ileostomycolostomy s 3
- Ileostomycolostomy s 4
- Ileostomycolostomy s 5
- Headache Location
- Frequency_4
- Other_22
- Migraine Frequency
- Site_2
- Weakness UE LE Location
- Other specify_7
- Site_3
- IV
- Pump typespecify
- Hand grips Equal Unequal specify
- Feedings Type amtrate
- Strong Weak specify
- Psychotropic drug use specify
- Flush Protocol amtspecify
- DoseFrequency
- Other_23
- Other specify 1_3
- Other specify 2_3
- DressingSite care specify 1
- DressingSite care specify 2
- Interventions instructionsComments 1
- Interventions instructionsComments 2
- Following Un
- versalStandard precautions
- NA
- No Problem_2
- Pain Frequency
- Abdominal girth
- Bowel sounds active absent hypo hyperactive x
- 3 Forgetful Off
- 4 Depressed Off
- 6 Lethargic Off
- 5 Disoriented Off
- 7 Agitated Off
- 2 Comatose
- 8 Other Off
- Forgetful at times Off
- Irritable Off
- Anxious Off
- Alert Off
- Describe 1
- Describe 2
- undefined_61
- Needs interpreter
- Comments 1_4
- Comments 2_4
- Higher Educational Level
- Fracture location
- Swollen painful joints specify
- Explain
- Contractures Joint
- Spiritual resource
- Location_3
- Phone No
- Atrophy
- Other_27
- Explain 1
- Explain 2
- Decreased ROM
- Paresthesia
- Weakness
- Other_28
- Inappropriate followthrough in past
- Amputation BKAKUE RL specify 1
- Amputation BKAKUE RL specify 3
- Amputation BKAKUE RL specify 4
- Treatment
- Treatment_2
- Other specify 1_4
- Other specify 2_4
- History of Falls past 3 months 12 falls M1032
- V s on Status Poor w or w o glasses M1200
- Vision Status Poor Legally blind M1200
- Gait and Balance Balance problem while standing
- Gait and Ba ance Balance problem while walking
- Gait and Balance Decreased muscular coordination
- Pred spos ng D seases 12 present
- Predisposing D seases 3 or more present
- Equipment Issues Oxygen tubing
- 1Row1
- PlanComments 1
- PlanComments 2
- Comment_2
- undefined_62
- b Ambulation
- c Transfer
- DOther specify
- 7Independent in home 1
- 7Independent in home 2
- Other 1_3
- Other 2_3
- Typebrand
- Size
- Gauge
- Length
- Insertion site
- Insertion date
- Flush solution
- Frequency_5
- Injection cap change frequency
- Dressing change frequency
- Other_29
- Siteskin condition
- External catheter length
- OtherComment
- fluid overload Other
- Circumference of arm
- Huber gaugelength
- Yes date
- Last flushed date
- Siteskin condition_2
- Infusion solution typevolumerate
- Dressing
- OtherComment 1
- OtherComment 2
- Drug Name
- Dose
- Route
- Frequency_6
- Duration of therapy
- Drug Name_2
- Dose_2
- Route_2
- Frequency_7
- Duration of therapy_2
- CommentPlan 1
- CommentPlan 2
- Pump type specify
- Other_30
- Lab draws
- Infusion care provided during visit 1
- Infusion care provided during visit 2
- Infusion care provided during visit 3
- Antibiotic therapy
- 1_7
- 2_8
- Other_31
- Removing line date if know
- BraceOrthotics specify 1
- BraceOrthotics specify 2
- BraceOrthotics specify 3
- Needs specify 1
- Needs specify 2
- Oxygen HME Co
- Prosthesis RUE RLE LUELLEOther
- HME Rep
- Grab bars BathroomOther
- Hospital bed Semielec Crank Spec
- Other_32
- NA_2
- Phone_5
- n care
- PlanComments
- N
- Other_33
- undefined_63
- Physical Therapy Total visits
- Speech Therapy Total visits
- visits
- Other Therapy Total visits
- Patient is not assessed to be at risk for falls
- No pain identified
- Patient has no pressure ulcers with need for moist wound healing
- O
- Noncompliance with drug orders
- Expected Outcome
- Patient unable to perform own Wound Care due
- Pat
- to
- Abd Pads Off
- Underpads size
- undefined_68
- Special mattress overlay
- Angiocatheter size
- Ostomy pouch brand size
- Pressure relieving device
- Ostomy wafer brand size
- undefined_69
- SYRINGES
- Batteries size
- Skin protectant
- Glucometer
- Hydrocolloids
- undefined_70
- FOLEYCATH SUPPLIES
- Syringes size
- size
- Oxygen concentrator
- Feeding tube
- Ointment
- Acetic acid
- Other 1_4
- Other 2_4
- Other 3
- Tens unit
- KLING 4
- Other 1_5
- Other 2_5
- Other 3_2
- PatientCG educationteaching this visit for
- MEDICATION Off
- DISEASE PROCESS COMPLICATIONS Off
- undefined_71
- SS OF Off
- ILEAL CONDUITOSTOMY Off
- DIET FLUIDS Off
- undefined_72
- undefined_73
- SKINFOOT CARE Off
- INFECTION CONTROL Off
- OTHER INSTRUCTIONS GIVEN
- Caregiver present during the visit
- NEEDS FURTHER TEACHING Off
- No_3
- Skilled Observation Assessment
- ent Educat
- Wound Care Dress
- Diabetic Observation Care
- Correct handwashing technique followed SG 1
- Correct handwashing technique followed SG 2
- Correct handwashing technique followed SG 3
- Correct handwashing technique followed SG 4
- 21 Included as reference only your Professional Staff must reviewupdatepersonalizedapprove the orders
- SN ORDERS FREQUENCYDURATION
- S COMPLICATIONS
- TH GLUCOMETER OR
- ON
- TEACH GLUCOMETER OR
- NSERTION
- TH
- INST DRESSING CHANGES
- MONITOR STATUS OF WOUND OR DECUBITUS place
- ADMINISTER PRESCRIBED INJECTABLE
- USING
- TH_2
- TH_3
- AND APPLY
- CLEANSE WOUND WITH
- NSE WITH
- AND APPLY_2
- OTHER_2
- DE ORDERS FREQUENCYDURATION
- PT ORDERS FREQUENCYDURATION
- OT ORDERS FREQUENCYDURATION
- ST ORDERS FREQUENCYDURATION
- MSW ORDERS FREQUENCYDURATION
- Included as reference only your Professional Staff must reviewupdatepersonalizeapprove the goals 22
- MRMS
- PROGRAM WITHIN
- CORRECT BODY MECHANICS WITHIN
- COMMUNICATIONS SYSTEMS WITHIN
- undefined_75
- undefined_76
- Date_14
- QA Date Reviewed
- undefined_77
- undefined_78
- Data Entry Date Locked
- undefined_79
- undefined_80
- Date Submitted
- undefined_81
- undefined_82
- SOCD
- SOCM
- SOCY
- SOCM1
- SOCD1
- SOCY1
- Check Box2 Off
- Check Box3 Off
- Check Box4 Off
- TOM
- TOD
- TOY
- FDM
- FDD
- FDY
- Prov 1071523
- BrID
- Check Box9 Yes
- BrIDno
- Check Box11 Off
- DLCM
- DLCD
- DLCY
- LVM
- LVD
- LVY
- DNR1 Off
- Check Box19 Off
- STFL
- PZC
- MCN
- NOMC Off
- SSN1
- SSN2
- SSN3
- SSUK Off
- MAN
- MAUK Off
- DOBM
- DOBD
- DOBY
- SEX Off
- MR
- First
- MI
- Last
- Suffix
- RACE2 Off
- RACE3 Off
- RACE4 Off
- RACE5 Off
- RACE1 Off
- RACE6 Off
- PS3 Off
- PS0 Off
- PS1 Off
- PS4 Off
- PS5 Off
- PS6 Off
- PS7 Off
- PS8 Off
- PS9 Off
- PS10 Off
- PS11 Off
- PS2 Off
- PSUK Off
- Ecode
- COMP Off
- DACM
- DACD
- DACY
- REA Off
- DM
- DD
- DY
- RDM
- RDD
- RDY
- REFDM
- REFDD
- REFDY
- EPT Off
- 14D2 Off
- 14D3 Off
- 14D4 Off
- 14D5 Off
- 14D6 Off
- 14D7 Off
- 14D8 Off
- Check Box39 Off
- icd9c
- icd9a
- icd9b
- icd9d
- icd9e
- icd9f
- Check Box5 Off
- Check Box7 Off
- icd9b2
- icd9c2
- icd9d2
- C_2
- icd9e2
- icd9f2
- icd9a2
- icd9b3
- icd9c3
- C_3
- icd9a3
- icd9d3
- 1005d
- 1005m
- 1005y
- 1018-2 Off
- 1018-1 Off
- 1018-4 Off
- 1018-5 Off
- 1018-6 Off
- 1018-7 Off
- 1018-NA Off
- 1018-UK Off
- 1018-3 Off
- 1012-na Off
- 1012-uk Off
- Radio Button11 Off
- v1020b
- C_5
- e_5
- f_5
- C_6
- e_6
- f_6
- c_4
- e_4
- f_4
- v1020c
- v1020d
- v1020e
- v1020f
- v1020a
- e1020b
- e1020c
- e1020d
- e1020e
- e1020f
- e1020a
- ev1020b
- ev1020c
- ev1020d
- ev1020e
- ev1020f
- ev1020a
- sp12-1
- sp12-2
- Radio Button12 Off
- Radio Button13 Off
- rad0 Off
- rae0 Off
- rdf0 Off
- phhp Off
- phrp1 Off
- phot1 Off
- phoa1 Off
- phfc1 Off
- phca1 Off
- phin1 Off
- phga1 Off
- phif1 Off
- phsg1 Off
- phwd1 Off
- phdc1 Off
- phgn1 Off
- rddmi Off
- imin Off
- inh1n1 Off
- fwpn Off
- fwtn Off
- fwot Off
- phdm1 Off
- PHNY Off
- phcd1 Off
- 10304 Off
- 10301 Off
- 10302 Off
- 10303 Off
- 10327 Off
- M1034 Off
- HBR1 Off
- HBR2 Off
- HBR3 Off
- HBR4 Off
- HBR5 Off
- HBR6 Off
- HBR7 Off
- HBR8 Off
- HBR9 Off
- HBR11 Off
- HBR12 Off
- HBR10 Off
- HBR13 Off
- SOBFT
- 10321 Off
- 10322 Off
- 10333 Off
- 10324 Off
- 10325 Off
- 10336 Off
- M11001 Off
- M1100b Off
- M1100c Off
- Relationshiphealth statusability to help 1
- 10361 Off
- 10362 Off
- 10363 Off
- 10364 Off
- 10365 Off
- 10366 Off
- 1210d Off
- 1210an Off
- 1210hea Off
- 1210OTH Off
- 1210TIN Off
- 1210NP Off
- 12102 Off
- 12101 Off
- 1210uk Off
- 1210h Off
- 1210v Off
- 1200CAT Off
- 1200OTH Off
- 1200JA Off
- 1200CATRL Off
- 1200OTHER Off
- 1200PT Off
- 1200GLAU Off
- 1200NOP Off
- NOSECON Off
- NOSEEP Off
- NOSELS Off
- NOSESINP Off
- NOSEASG Off
- NOSEOTHSP Off
- NOSENP Off
- THROATDY Off
- TROATL Off
- THROATOTH Off
- 1200BV Off
- 1200LB Off
- THROATHO Off
- THOATSO Off
- THROATNP Off
- 1200GL Off
- 1200CO Off
- 1200PR Off
- 1200IN Off
- M1200 Off
- M1220 Off
- M1230 Off
- MOUTHMas Off
- MOUTHGI Off
- MOUTHULC Off
- MOUTHTOO Off
- MOUTHANY Off
- MOUTHOTH Off
- MOUTHNP Off
- M1240 Off
- M1242 Off
- MOUTHDE Off
- MOUTHUP Off
- MOUTHLO Off
- MOUTHPAR Off
- COPYN Off
- MKMEDP Off
- CPCYN Off
- DPRYN Off
- ICPYN Off
- TURGGP Off
- BESTPAINSC2
- WORSES2
- BESTPAINSC
- WORSESC
- BESTPAINSC3
- WORSESC3
- FACESOBS Off
- SCALE010 Off
- WPSL Off
- WPMA Off
- WPMV Off
- WPAMB Off
- WPIMM Off
- WPTR Off
- WPOTH Off
- WPNP Off
- NVIM Off
- WRP4 Off
- WRP5 Off
- WRP6 Off
- WRP7 Off
- WRP8 Off
- WRP9 Off
- WRPOTH Off
- TKMEDNV Off
- TKMEDLDD Off
- TKMEDD Off
- TKMED23 Off
- TKMEDLT3 Off
- PCTSL Off
- PTXSEN Off
- PTXSEV Off
- PTXSECF Off
- PRDOCC Off
- PTXSEOTH Off
- PRDCONT Off
- WRP1 Off
- WRP2 Off
- WRP3 Off
- PRDINT Off
- PRDFRQ Off
- PHYNOTPT Off
- PHYNOTSTF Off
- NVIG Off
- NVIC Off
- NVIAF Off
- DMIJUV Off
- DMTPII Off
- INSDGFQ Off
- DMODIET Off
- ADMOTH Off
- symphyg Off
- sympfat Off
- symhypog Off
- endopcgr Off
- endopostpra Off
- endorand Off
- endolab Off
- bsrange Off
- bsranptcg Off
- endomonsf Off
- endomoncg Off
- endomonsn Off
- endomonoth Off
- dmNapb Off
- othendopb Off
- enlthyr Off
- intoheatcol Off
- endonp Off
- HEMAANE Off
- HEMABLEED Off
- HEMAHEMO Off
- HEMAINMO Off
- HEMAOTH Off
- HEMANP Off
- SKINITCH Off
- SKINRASH Off
- SKINDRY Off
- SKINSCL Off
- SKINRED Off
- SKINBRU Off
- SKINECCH Off
- SKINPALL Off
- SKINJAU Off
- ADMSELF Off
- ADMSCGF Off
- ADMNURS Off
- SKINNP Off
- m1300 Off
- M1302 Off
- M1306 Off
- M1320 Off
- M1322 Off
- M1324 Off
- M1330 Off
- M1332 Off
- M1334 Off
- M1340 Off
- M1342 Off
- M1350 Off
- WCPYN Off
- IPDMYN Off
- APHYN Off
- SDRBY Off
- SDRSN Off
- SDRCG Off
- SDRPT Off
- SDROTH Off
- TECST Off
- TECCL Off
- WDCLW Off
- WDIRRW Off
- WDPKW Off
- WDDREW Off
- DBFEXD Off
- DBFEX2D Off
- DBFEXEOD Off
- DFEX2WK Off
- DBNFEXWK Off
- DFEXOTH Off
- PDPPRL Off
- PDPARL Off
- LSWRL Off
- endobm Off
- endotv Off
- fbs Off
- LSCDRL Off
- ASCCFR Off
- ASCCFL Off
- Right for
- ASCCFLF
- TRINR Off
- BURRL Off
- LEGHP Off
- LEGHAB Off
- DBFEXRN Off
- DFEXCG Off
- DBFEXPT Off
- DBFEXOT Off
- EXSER Off
- EXSERG Off
- EXSANG Off
- EXSER2 Off
- EXSERG2 Off
- EXSANG2 Off
- SHOV Off
- SHAPRD Off
- SHAPOTH Off
- SHOV2 Off
- SHAPRD2 Off
- SHAPOTH2 Off
- cm length
- cm length2
- DBFTEXRNPT Off
- EXDYN Off
- EXDYN2 Off
- APHYN2 Off
- APHYN3 Off
- Loc3w
- Loc2w
- Loc1w
- Loc4w
- Typew1
- Typew2
- Typew3
- Typw4
- sizw3
- tunnw3
- surrw1
- stomaw1
- surrw1a
- stomaw1a
- surrw3
- surrw3a
- stomaw3
- stomaw3a
- surrw2
- surrw2a
- stomaw2
- stomaw2a
- surrw4
- surrw4a
- stomaw4
- stomaw4a
- statgew2
- statgew3
- Odorw2
- Odorw3
- Edemaw2
- Edemaw3
- appw2
- appw3
- Treatment Ordered_2
- Treatment Ordered_3
- Group10 Off
- draick2 Off
- driack3 Off
- draick4 Off
- colw11 Off
- colw12 Off
- colw31 Off
- colw32 Off
- colw33 Off
- colw34 Off
- colw21 Off
- colw22 Off
- colw23 Off
- colw24 Off
- colw43 Off
- colw44 Off
- ital1u1 Off
- ital1u2 Off
- fsrrepo Off
- frsact Off
- rwgchpt Off
- rwgchcgf Off
- rwgchnur Off
- pulreg1 Off
- pulirreg1 Off
- fsrrespreg Off
- colw41 Off
- colw42 Off
- bpsitly Off
- bpstand Off
- fsrwgrep Off
- fsrwgact Off
- tempaxil Off
- temptymp Off
- pulseappical Off
- pulseradial Off
- pulsebrach Off
- pulsecarot Off
- pulserest Off
- pulsecheyn Off
- pulseactiv Off
- respirirreg Off
- respideath Off
- respaccess Off
- respiapnea Off
- bsckrack Off
- temporal Off
- temprect Off
- chestprad Off
- colw13 Off
- colw14 Off
- consth2 Off
- consthic2 Off
- consth3 Off
- consthic3 Off
- consth4 Off
- consthic4 Off
- chestpyes Off
- chestpainno Off
- consth1 Off
- consthic1 Off
- cpsubstern Off
- cpviselike Off
- dm5lin
- assocwithsoboe Off
- associawactv Off
- associwsweat Off
- cphowreloth Off
- cphowrelrest Off
- cphowrelmeds Off
- cppalarr Off
- cppalpfast Off
- cppalpslow Off
- cppalpfatig Off
- cpedema Off
- cpedemapedal Off
- cpangina Off
- cppostural Off
- cplocalized Off
- cpedempedrig Off
- cpedemapedallef Off
- cpedemasacral Off
- cpedemadepend Off
- cpedemapitt Off
- cpedemanonpitt Off
- cstcramp Off
- cardstclaud Off
- cardstcapref Off
- cstcaprefless Off
- castcaprefgreat Off
- csthsreg Off
- csthsirreg Off
- csthsmurmur Off
- cstpacemak Off
- cpstabreassouclear Off
- breassodwheez Off
- bresddimm Off
- chestpaidull Off
- cpache Off
- cpsharp Off
- brsdabset Off
- brsdsobsoboe Off
- brsdsobonmineff Off
- 14001 Off
- 14003 Off
- 14004 Off
- 1400tva Off
- 14002 Off
- 1400car Off
- 14101 Off
- 14102 Off
- 14103 Off
- 14104 Off
- uroops Off
- uropat Off
- urocare Off
- 14000 Off
- urosn Off
- Radio Button2 Off
- 16100 Off
- 16101 Off
- 1400pat Off
- 16concar Off
- 162gm Off
- 16nas Off
- 16npo Off
- 16102 Off
- 161800cal Off
- 16lowfat Off
- 16lowcho Off
- 16incflu Off
- 16restflu Off
- 16exc Off
- 16good Off
- 16fair Off
- 16poor Off
- 16anore Off
- 16nau Off
- 16vom Off
- 16heabur Off
- O2satur
- O2firesaf Off
- O2sn Off
- O2carefamother Off
- O2cough Off
- O2no Off
- O2yes Off
- O2nonprod Off
- O2noc Off
- O2yesc Off
- O2dys Off
- O2rest Off
- O2dADL Off
- O2sliplo Off
- O2nop Off
- O2yesp Off
- 16other Off
- genibur Off
- genihes Off
- genihema Off
- geniolig Off
- geniurg Off
- geninoc Off
- geniincon Off
- geniuri Off
- genidiap Off
- 16lowna Off
- genicyell Off
- genicamber Off
- genicbr0 Off
- genicbt Off
- genicother Off
- genicla Off
- geniclo Off
- genised Off
- geniodno Off
- genifol Off
- geniwitdif Off
- genisup Off
- geniyes Off
- genino Off
- 1620 Off
- 1615 Off
- 1630 Off
- 1630cosn Off
- 1630lBM Off
- 1630diar Off
- 1630rect Off
- 1630hemo Off
- 1630incon Off
- 1630diap Off
- 1630lax Off
- 1630w Off
- 1630d Off
- 1630m Off
- 1630lleost Off
- 1630pat Off
- 1630car Off
- 1630sn Off
- 1630ot Off
- 1630np Off
- 1630follow Off
- genblis Off
- genmass Off
- gencys Off
- genwart Off
- geninf Off
- gensurg Off
- genprost Off
- gensef Off
- genmeno Off
- genhyst Off
- gendisc Off
- geniodyes Off
- gennp Off
- 1630flat Off
- 17001 Off
- 17002 Off
- 17004 Off
- 1700head Off
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- 1700paral Off
- 1700stu Off
- 1700halluc Off
- 1700psy Off
- 1700oth Off
- 1700np Off
- EFAD TPN Off
- 17003 Off
- EFAD jej Off
- EFAD iv Off
- EFAD pum Off
- EFDA bol Off
- EFDA con Off
- EFA pat Off
- EFDA sn Off
- EFDA car Off
- EFDAoth Off
- EFDAfu Off
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- EFDA np Off
- abd pa Off
- ABD dis Off
- ABD hard Off
- ABD soft Off
- ABD asc Off
- ABD ab Off
- ABD oth Off
- ABD bow Off
- ABD other Off
- ABD ten Off
- EFAD Nas Off
- efad gas Off
- EFAD ot Off
- 17101 Off
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- gen dis Off
- genbre Off
- genmast Off
- genoth Off
- 1700fin Off
- 1700mig Off
- genles Off
- 1630 other Off
- 1730 Off
- 1745 Off
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- 17000 Off
- 17401 Off
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- 17406 Off
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- 1 Oriented Off
- msnp Off
- pslb Off
- psni Off
- psd Off
- psnas Off
- lbm Off
- lbps Off
- lbph Off
- lbf Off
- lbs Off
- urw Off
- sceri Off
- 17403 Off
- ps Off
- ABD pn Off
- pslm Off
- psdp Off
- pspl Off
- psrf Off
- psnh Off
- psue Off
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- pse Off
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- psea Off
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- psin Off
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- msor Off
- msfr Off
- msre Off
- msp Off
- mssw Off
- mscon Off
- msat Off
- msad Off
- mscan Off
- msuns Off
- mstp Off
- mswal Off
- msdec Off
- par Off
- msot Off
- mssh Off
- mswe Off
- mswea Off
- mskp Off
- msother Off
- mshe Off
- mspa Off
- msqua Off
- msoth Off
- msnop Off
- psina Off
- pssi Off
- psnap Off
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- psan Off
- psfat Off
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- psdif Off
- psdis Off
- psdep Off
- psanx Off
- psnp Off
- psade Off
- psdisc Off
- mscom Off
- msamp Off
- FL2 Off
- FL3 Off
- FL7 Off
- FL8 Off
- FL9 Off
- FLA-d Off
- FLb Off
- FLg Off
- FLart Off
- FLdiz Off
- FLhead Off
- FLins Off
- FLanx Off
- FLsob Off
- FLpoor Off
- FLprod Off
- FLheart Off
- FLp Off
- FLu Off
- FLv Off
- FLed Off
- FLc Off
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- FL1l Off
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- FL1d Off
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- FL1lc Off
- FL1f Off
- FL1n Off
- FL4 Off
- FL6 Off
- FL5 Off
- adl o Off
- adl 1 Off
- adl 2 Off
- adl 3 Off
- 1810 0 Off
- 1810 1 Off
- 18102 Off
- 18103 Off
- 19100 Off
- 18200 Off
- 18201 Off
- 18202 Off
- 18203 Off
- FL1 Off
- 1910sg Off
- 1910sgp Off
- 1910sgd Off
- 1111910sgp Off
- 1910sgo Off
- 18302 Off
- 18301 Off
- 18300 Off
- 18304 Off
- 18305 Off
- 18306 Off
- 18400 Off
- 18401 Off
- 18402 Off
- 18403 Off
- 18404 Off
- 1910sgpat Off
- 18901 Off
- 18902 Off
- 18903 Off
- 18904 Off
- 18905 Off
- 1890na Off
- adlr Off
- adlna Off
- adlsn Off
- adlm Off
- adlp Off
- adlot Off
- adlst Off
- 18303 Off
- adlcom Off
- 1845 Off
- 1880 Off
- adl Off
- 1850 Off
- 1860 Off
- 1870 Off
- 1900a Off
- 1900b Off
- 1900d Off
- 1900c Off
- 18900 Off
- 19101 Off
- 19102 Off
- 19103 Off
- 19104 Off
- 19105 Off
- 19106 Off
- 19107 Off
- 19108 Off
- 19109 Off
- 1910aw Off
- 1910bw Off
- 1910cnr Off
- 1910do Off
- alleasp Off
- alleggs Off
- alleib Off
- allesulf Off
- allead Off
- alledm Off
- allelod Off
- allepol Off
- alledust Off
- alleother Off
- 20000 Off
- 2000na Off
- 14D1 Off
- 20001 Off
- 20002 Off
- 2010 Off
- 2002 Off
- 2040a Off
- 2040b Off
- 2020 Off
- 2030 Off
- infpat Off
- picccir Off
- ivadacc Off
- int Off
- fo Off
- fa Off
- ule Off
- infiv Off
- perip Off
- mc Off
- gros Off
- tun Off
- nt Off
- ld Off
- lt Off
- cl Off
- pat Off
- rn Off
- cg Off
- ivocc Off
- ivflu Off
- res Off
- red Off
- allerno Off
- iv-i Off
- adp Off
- adc Off
- adrn Off
- adoth Off
- pia Off
- athe Off
- eiv Off
- biood Off
- mva Off
- pn Off
- infna Off
- infcare Off
- rldna Off
- 2100a Off
- 2100b Off
- 2100c Off
- 2100d Off
- 2100e Off
- 2100f Off
- 2100g Off
- 2110 Off
- asheb Off
- ashmet Off
- asehmop Off
- asprost Off
- asebed Off
- aseshow Off
- asescoot Off
- asehoist Off
- asegrab Off
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- aselif Off
- asewhee Off
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- aseneed Off
- aseoxy Off
- asefire Off
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- asena Off
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- pump Off
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- smwd Off
- smal Off
- smpco Off
- smpfi Off
- smsa Off
- smpic Off
- smsp Off
- smtsc Off
- smsd Off
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- smgup Off
- smst Off
- smcc Off
- smpes Off
- smep Off
- smms Off
- smcp Off
- smcpat Off
- smcht Off
- smcfsh Off
- smpsbp Off
- smoth Off
- oxgava Off
- oxknosw Off
- prr Off
- shan Off
- adi Off
- epci Off
- apn Off
- cih Off
- pmi Off
- sphic Off
- acihsf Off
- dcdmi Off
- dnr Off
- sac Off
- opnc Off
- msr Off
- hsg Off
- asii Off
- gp Off
- fpp Off
- other Off
- pttv Off
- ottv Off
- sttv Off
- ottvist Off
- oxu Off
- oxupe Off
- oufsp Off
- sh Off
- ih Off
- hd Off
- fab Off
- ug Off
- ir Off
- us Off
- nta Off
- pp Off
- mss Off
- ep Off
- ev Off
- sb Off
- adce Off
- sf Off
- ppf Off
- rma Off
- hsd Off
- ppnf Off
- dfc Off
- fpi Off
- dim Off
- imm Off
- ipp Off
- put Off
- cp Off
- ph Off
- sn Off
- ot Off
- st Off
- aid Off
- oth Off
- mfc Off
- nch Off
- oo Off
- mmc Off
- idt Off
- sse Off
- sdi Off
- ncwdo Off
- ddt Off
- eo Off
- no so-cg Off
- nancg Off
- salin Off
- 2x2 Off
- 4x4 Off
- abd Off
- telf Off
- tap Off
- wg Off
- glov Off
- ns Off
- hyd Off
- ks Off
- td Off
- oint Off
- cs Off
- ther Off
- rb Off
- ic Off
- ivsk Off
- ivp Off
- ivt Off
- as Off
- asi Off
- per Off
- et Off
- cid Off
- ip Off
- ss Off
- duo Off
- bs Off
- abs Off
- m2x11 Off
- mt2 Off
- s4x4 Off
- ng Off
- und Off
- ec Off
- ub Off
- op Off
- ow Off
- sat Off
- fol Off
- ls Off
- sc Off
- tc Off
- aa Off
- otth Off
- app Off
- chem Off
- cta Off
- dcfg Off
- hyt Off
- it Off
- syr Off
- glu Off
- es Off
- ft Off
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- is Off
- stst Off
- ta Off
- vg Off
- kl Off
- sr Off
- bath Off
- can Off
- com Off
- smo Off
- prd Off
- egg Off
- hb Off
- hl Off
- efp Off
- neb Off
- oc Off
- pup Off
- pui Off
- or Off
- inj Off
- ivinf Off
- inh Off
- pcbp Off
- fcc Off
- pe Off
- wcd Off
- pai Off
- doc Off
- soa Off
- injr Off
- pt Off
- sup Off
- atu Off
- qc Off
- sd Off
- cht Off
- mep Off
- ncfa Off
- dpd Off
- wdc Off
- dmc Off
- iad Off
- gc Off
- nmd Off
- trc Off
- oca Off
- fc Off
- pfv Off
- oup Off
- uhm Off
- pmh Off
- eim Off
- e911 Off
- puitc Off
- cpdv Off
- dpdp Off
- rp Off
- ko Off
- ipai Off
- iop Off
- iudp Off
- dc Off
- ds Off
- spe Off
- sfcp Off
- ispm Off
- npp Off
- fi Off
- issi Off
- cqm Off
- idc Off
- msw Off
- iicm Off
- ign Off
- ret Off
- mrw Off
- pcd Off
- dccw Off
- ort Off
- epum Off
- meac Off
- pebp Off
- iap Off
- iiph Off
- iccs Off
- ipc Off
- icdb Off
- ipm Off
- ipap Off
- eiad Off
- ipaot Off
- odit Off
- mepc Off
- ttdp Off
- scwc Off
- mr Off
- dn Off
- cef Off
- pcm Off
- si Off
- spi Off
- eplan Off
- oa Off
- nmbs Off
- tg Off
- idp Off
- ipd Off
- icid Off
- igp Off
- ief Off
- ida Off
- nss Off
- api Off
- aps Off
- pst Off
- sib Off
- sdp Off
- ippph Off
- aperi Off
- pf Off
- ap Off
- apv Off
- pa Off
- ans Off
- imb Off
- imt Off
- ewl Off
- acb Off
- mlc Off
- eob Off
- afs Off
- paa Off
- rt Off
- das Off
- got Off
- lsm Off
- dpc Off
- ils Off
- mpb Off
- iao Off
- ihc Off
- mfs Off
- ipcp Off
- tae Off
- iua Off
- tsb Off
- pc Off
- hc Off
- sp Off
- mdc Off
- oh Off
- tpr Off
- ad Off
- awa Off
- psm Off
- gs Off
- wc Off
- lhk Off
- awpc Off
- errand Off
- nlb Off
- fnc Off
- pric Off
- rsf Off
- src Off
- ebc Off
- ppt Off
- gtwa Off
- ebp Off
- eem Off
- nme Off
- nsf Off
- bmt Off
- thm Off
- tt Off
- ism Off
- ephs Off
- irle Off
- isc Off
- atp Off
- mre Off
- te Off
- pas Off
- sfe Off
- pom Off
- sad Off
- isp Off
- fsm Off
- idy Off
- vdt Off
- ar Off
- noc Off
- ldt Off
- mfa Off
- crm Off
- crp Off
- lrp Off
- mrms Off
- sps Off
- acmr Off
- hwi Off
- hdic Off
- psn Off
- dsdc Off
- usb Off
- dcw Off
- saic Off
- dptw Off
- rsm Off
- kss Off
- uhc Off
- hpa Off
- ipi Off
- grp Off
- ftcm Off
- wac Off
- ria Off
- paf Off
- pafi Off
- pwe Off
- ptc Off
- ges Off
- otp Off
- pwdf Off
- pdaf Off
- pdi Off
- pdis Off
- phas Off
- pep Off
- 12100 Off
- allepen Off
- Patient is not diabetic or is bilateral amputee
- mswref Off
- genitonoprob Off
- Urostomy describe skin around stoma Off
- nutrinoprob Off
- O2prod Off
- woraft Off
- woreve Off
- wormor Off
- worsleep Off
- prodsputcol
- fname Off
- Rehabdc1 Off
- mswgwk1
- stgwk2
- stgwk1
- stgwk3
- rhpoor Off
- Clear Form
- E-mail Form
NEURO EMOTIONAL BEHAVIOR STATUS (Contd)(M1730) Depression Screening Has the patient been screened for depression using a standardized depression screening tool
0 - No1 - Yes patient was screened using the PHQ-2 scale (instructions for this two-question tool Ask patient Over the last two weeks how often
have you been bothered by any of the following problems)
PHQ-2copy Not at All0-1 Day
Several Days2-6 Days
More Than Halfof the Days7-11 Days
Nearly Every Day12-14 Days
NAUnable toRespond
a) Little interest or pleasure in doing things 0 1 2 3 na
b) Feeling down depressed or hopeless 0 1 2 3 na
2 - Yes with a different standardized assessment and the patient meets criteria for further evaluation for depression3 - Yes patient was screened with a different standardized assessment and the patient does not meet criteria for further evaluation for depression
Copyright Pfizer Inc All rights reserved Reproduced with permission
(M1745) Frequency of Disruptive Behavior Symptoms (Reported orObserved) Any physical verbal or other disruptivedangerous symptomsthat are injurious to self or others or jeopardize personal safety
(M1740) Cognitive behavioral and psychiatric symptoms that aredemonstrated at least once a week (Reported or Observed)
(Mark all that apply)1 - Memory deficit failure to recognize familiar personsplaces 0 - Never
inability to recall events of past 24 hours significant memory lossso that supervision is required 1 - Less than once a month
2 - Once a month2 - Impaired decision -making failure to perform usual ADLs or IADLs 3 - Several times eachinability to appropriately stop activities jeopardizes safety through
actions3 -Verbal disruption yelling threatening excessive profanity
references etc4 - Physical aggression aggressive or combative to self and others
(eg hits self throws objects punches dangerouswith wheelchair or other objects)
5 - Disruptive infantile or socially inappropriate behavior (excludesverbal actions)
6 - Delusional hallucinatory or paranoid behavior7 - None of the above behaviors demonstrated
IMENTAL STATUS Inability to cope with altered health statusillness as evidenced by
1 - Oriented 5 - DisorientedLack of motivation
2 - Comatose Unrealistic expectations3 - Forgetful
Inability to recognize problems 4 - Depressed Denial of problems
ActualPotentialEvidence of abuse neglect exploitationVerbalEmotionalPsychologicalIntervention
FinancialPhysical
PSYCHOSOCIALSENSORY STATUS Describe
Comments
MUSCULOSKELETAL STATUS
Primary language
Learning barrier Mental Psychological Physical Functional Sensory
Unable to readwrite Higher Educational Level
Spiritual CulturalEthnicReligion implications that impact care
No Problem
Explain
Fracture (location)
Swollen painful joints (specify)
Spiritual resourceContractures JointLocation
Phone No Assistive DeviceAtrophySleepRest Adequate Inadequate
Decreased ROM ParesthesiaExplainShuffling Wide-based gait Weakness
Amputation BKAKUE RL (specify)Inappropriate responses to caregiversphysicianclinician staffInappropriate follow-through in pastAngry
ParaplegiaFlat affect
Hemiplegia QuadriplegiaDiscouraged
Other (specify)Withdrawn Difficulty coping DisorganizedDepressed RecentLong term
Treatment
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4 - Several times a week 5 - At least daily
(M1750) Is this patient receiving Psychiatric Nursing Services at homeprovided by a qualified psychiatric nurse
0 - No1 - Yes
MENTAL STATUS
6 - Lethargic7 - Agitated
8 - Other
Language barrier Needs interpreter
Patient Name Med Record
wwwpnsystemcom 3058185940 The Outcome and Assessment Information Set (OASIS) is the intellectual property of the Center for Health Services and Policy Research Denver Colorado It is used with permission Expiration date 7312012
19
Forgetful at times Irritable Anxious Alert
No Problem
English SpanishOther
Deaf Needs American Sing language interpreter
Anxiety RecentLong termTreatment
No Problem
Creole Russian
Sometimes Inadequate
Not hope in recovery
Refuse to follow MD orders
Abandon
PSYCHOLOGICAL STATUS (Contd)
No Problem
Orthopedic cast Removable Permanent for days
Unsteady Gait Transfer ProblemsWheelchair Cane
Walker Other
Orthopedic Protesys Knee Replacement L R Other
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FUNCTIONAL LIMITATIONS ADLIADLs
(M1800) Grooming Current ability to tend safely to personal hygiene7-Ambulationneeds (ie washing face and hands hair care shaving or make up
1 -Amputation
teeth or denture care fingernail care) 2-BowelBladder 8-Speech
0 - Able to groom self unaided with or without the use of assistive(incontinence)
9-Legally blinddevices or adapted methods
3 - Contracture
A -Dyspnea with
1 - Grooming utensils must be placed within reach before able to
4-Hearing
complete grooming activities
B- Other (specify)
5-Paralysis
2 - Someone must assist the patient to groom self
6-Endurance
3 - Patient depends entirely upon someone else for grooming needs
(M1810) Current Ability to Dress Upper Body safely (with or withoutdressing aids) including undergarments pullovers front-opening shirtsand blouses managing zippers buttons and snaps
FALL RISK ASSESSMENT 0 - Able to get clothes out of closets and drawers put them on and
remove them from the upper body without assistance1 - Able to dress upper body without assistance if clothing is laid out
or handed to the patient2 - Someone must help the patient put on upper body clothing3 - Patient depends entirely upon another person to dress the upper
body
(M1830) Bathing Current ability to wash entire body safely Excludes grooming (washing face washing hands and shampooing hair)
1 - With the use of devices is able to bathe self in shower or tubindependently including getting in and out of the tubshower
2 - Able to bathe in shower or tub with the intermittent assistance ofanother person(a) for intermittent supervision or encouragement or reminders
OR(b) to get in and out of the shower or tub OR(c) for washing difficult to reach areas
3 - Able to participate in bathing self in shower or tub but requirespresence of another person throughout the bath for assistance orsupervision
4 - Unable to use the shower or tub but able to bathe selfindependently with or without the use of devices at the sink inchair or on commode
5 - Unable to use the shower or tub but able to participate in bathing
(M1910) Has this patient had a multi-factor Fall Risk Assessment (suchas falls history use of multiple medications mental impairment toiletingfrequency general mobilitytransferring impairment environmentalhazards)
self in bed at the sink in bedside chair or on commode with theassistance or supervision of another person throughout the bath
6 - Unable to participate effectively in bathing and is bathed totally byanother person
0 - No multi-factor falls risk assessment conducted
(M1840) Toilet Transferring Current ability to get to and from the toiletor bedside commode safely and transfer on and off toiletcommode
1 - Yes and it does not indicate a risk for falls2 - Yes and it indicates a risk for falls
0 -Able to get to and from the toilet and transfer independently withor without a device
PlanComments
1 -When reminded assisted or supervised by another person ableto get to and from the toilet and transfer
2 - Unable to get to and from the toilet but is able to use a bedsidecommode (with or without assistance)
3 - Unable to get to and from the toilet or bedside commode but isable to use a bedpanurinal independently
4 - Is totally dependent in toileting
Page 13 of 20
(M1820) Current Ability to Dress Lower Body safely (with or without)dressing aids) including undergarments stacks socks or nylons shoes 0 - Able to obtain put on and remove clothing and shoes without
assistance 1 - Able to dress lower body without assistance if clothing and shoes
are laid out or handed to the patient
2 - Someone must help the patient put on undergarments slackssocks or nylons and shoes
3 - Patient depends entirely upon another person to dress lower body
0 - Able to bathe self in shower or tub independently includinggetting in and our of tubshower
Patient Name Med Record
wwwpnsystemcom 3058185940 The Outcome and Assessment Information Set (OASIS) is the intellectual property of the Center for Health Services and Policy Research Denver Colorado It is used with permission Expiration date 7312012
18A
Dizziness
Generalized WeaknessArthralgia
InsomniaHeadache
AnxietySOB on exertion
Heartburn
Poor vision
Productive cough
Unsteady GaitPain on ambulation
Varicositis on lower extEdema in __________
Legs weak
Chest pain on exertionFatigues at times
Decreased Bil breath soundsBack Pain
PalpitationsLimited MobilityLimited ROMLeg crampsFreq Coughing episodesNeeds assistance of 1 person
Implement fall precautions for a total score of 10 or greater
Patient Factors Circle appropriate score for each section and total score at bottom (MedQIC) ScoreLevel of Consciousness Mental Status Disoriented X 3 at all times (M1700) 2Level of Consciousness Mental Status Intermittent confusion (M1700 - M1710) 4History of Falls (past 3 months) 1-2 falls (M1032) 2History of Falls (past 3 months) 3 or more falls (M1032) 4Ambulation Elimination Status Chair bound amp requires assist w toileting (M1840) 2Ambulation Elimination Status Ambulatory amp incontinent (M1610 - M1615) 4Vision Status Poor (w or wo glasses) (M1200) 2Vision Status Poor (Legally blind) (M1200)Gait and Balance (Balance problem while standing)Gait and Balance (Balance problem while walking) 1
Gait and Balance (Decreased muscular coordination)
Gait and Balance (Change in gait pattern when walking through doorway) 1Gait and Balance (Jerking or unstable when making turns) 1Gait and Balance (Requires assistance (person furniturewalls or device))
Orthostatic Changes (Droplt20mmHg in BP between lying and standing Increase of cardiac rhythm lt20)
Orthostatic Changes (Drop gt20mmHg in BP between lying and standing Increase of cardiac rhythm gt20)
4
Predisposing Diseases (1-2 present)
Equipment Issues (Oxygen tubing) 1
Total points
4
1
1
2
Medications (Takes 1-2 of these medications currently or win past 7 days)
1
42
Medications (Takes 3-4 of these medications currently or win past 7 days)
Medications (Mark additional point if patient has had a change in these medications or doses in past 5 days) 1
2Predisposing Diseases (3 or more present) 4
Equipment Issues (Inappropriate or client does not consistently use assistive device)
Equipment Issues (Other ) 1
1Equipment Issues (Equipment needs ) 1
Established by the Centers for Medicare amp Medicaid Services (CMS) QualityNet provides healthcare quality improvement news resources and data reporting tools and applications used by healthcare providers and others
Additional service Needed-Impaired Mobility -History of Falls -Predisposing DX - Weakness --Knowledge Deficit or noncompliance with activity restrictions Physical Therapy
Order Obtained
-Unsafe Living Environment -Pt demo unsafe behavior or choices -Limited Resources -At risk and lives alone -Pt is CG for another
Medical Social Services
-ADLIADL Deficits -Sensory Deficits -Decreased Cognition-Unsafe living environment -UE limitations
Occupational Therapy
- - - - - - - -
- - - - - - - -
Certain abilities needed to function independently can be developed or maintained by managing symptoms or through physical or occupational therapy Home health staff needs to evaluate the need for any special assistance devices or equipment and trainpatients on their use If a patient can perform this activity with little assistance they are more independent self-confident and active
If no additional services requested check reasonDiscipline already ordered Pt has been assessed by this discipline win last 30 daysPatientFamily refused additional discipline
QA
(SOC)
SG
No other service approved by Patients Physician
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ADLIADLs (Contd)(M1880) Current Ability to Plan and Prepare Light Meals (eg cerealsandwich) or reheat delivered meals safely
(M1845) Toileting Hygiene Current ability to maintain perineal hygienesafely adjust clothes andor incontinence pads before and after usingtoilet commode bedpan urinal If managing ostomy includes cleaningarea around stoma but not managing equipment
0 - (a) Able to independently plan and prepare all light meals for selfor reheat delivered meals OR
0 - Able to manage toileting hygiene and clothing management (b) Is physically cognitively and mentally able to prepare lightwithout assistance meals on a regular basis but has not routinely performed light
meal preparation in the past (ie prior to this home careadmission)1 - Able to manage toileting hygiene and clothing management
without assistance if suppliesimplements are laid out for the1 - Unable to prepare light meals on a regular basis due to physicalpatient
cognitive or mental limitations2 - Someone must help the patient to maintain toileting hygiene2 - Unable to prepare any light meals or reheat any delivered mealsandor adjust clothing
3 - Patient depends entirely upon another person to maintain toileting(M1890) Ability to Use Telephone Current ability to answer the phonesafely including dialing numbers and effectively using the telephone tocommunicate
hygiene
(M1850) Transferring Current ability to move safely from bed to chairor ability to turn and position self in bed if patient is bedfast 0 - Able to dial numbers and answer calls appropriately and as
desired0 - Able to independently transfer 1 - Able to use a specialty adapted telephone (ie large numbers on
the dial teletype phone for the deaf) and call essential numbers1 -Able to transfer with minimal human assistance or with use of anassistive device 2 - Able to answer the telephone and carry on a normal conversation
but has difficulty with placing calls2 -Able to bear weight and pivot during the transfer process butunable to transfer self 3 - Able to answer the telephone only some of the time or is able to
carry on only a limited conversation3 - Unable to transfer self and is unable to bear weight or pivot when4 - Unable to answer the telephone at all but can listen if assistedtransferred by another person
with equipment4 - Bedfast unable to transfer but is able to turn and position self in5 - Totally unable to use the telephonebed
NA - Patient does not have a telephone5 - Bedfast unable to transfer and is unable to turn and position self
RefusedIndications for Home Health Aide may be needed
(M1860) AmbulationLocomotion Current ability to walk safely oncein a standing position or use a wheelchair once in a seated position ona variety of surfaces
NoYesMD Order obtained
OTSN MSWOther Services ordered STPT
0 - Able to independently walk on even and uneven surfaces and
Comment
negotiate stairs with or without railings (ie needs no humanassistance or assistive device)
1 - With the use of a one-handed device (eg cane single crutchhemi-walker) able to independently walk on even and uneven sur-faces and negotiate stairs with or without railings
2 - Requires use of a two-handed device (eg walker or crutches) to(M1900) Prior Functioning ADLIADL Indicate the patients usualability with everyday activities prior to this current illness exacerbationor injury Check only one box in each row
walk alone on a level surface andor requires human supervisionor assistance to negotiate stairs or steps or uneven surfaces
3 - Able to walk only with the supervision or assistance of another
Functional Area IndependentNeeded
Some HelpDependent
a Self-Care (eg groomingdressing and bathing) 0 1 2
b Ambulation 0 1 2
c Transfer 0 1 2
d Household tasks (eglight meal preparationlaundry shopping)
0
1 2
person at all times
4 - Chairfast unable to ambulate but is able to wheel selfindependently
5 - Chairfast unable to ambulate and is unable to wheel self
6 - Bedfast unable to ambulate or be up in a chair
(M1870) Feeding or Eating Current ability to feed self meals andsnacks safely Note This refers only to the process of eating chewinqand swallowing not preparing the food to be eaten
0 - Able to independently feed self
ACTIVITIES PERMITTED
1 - Able to feed self independently but requires(a) meal set-up OR(b) intermittent assistance or supervision from another person OR(c) a liquid pureed or ground meat diet 8-Crutches1 -Complete bedrest
9-Cane2-BedrestBRP2 -Unable to feed self and must be assisted or supervisedA-Wheelchair3-Up as toleratedthroughout the mealsnackB-Walker4-Transfer bedchair3 - Able to take in nutrients orally and receives supplemental nutrientsC-No restrictions5-Exercises prescribedthrough a nasogastric tube or gastrostomy
D-Other (specify)6-Partial weight bearing4 - Unable to take in nutrients orally and is fed nutrients through anasogastric tube or gastrostomy
7-Independent in home5 - Unable to take in nutrients orally or by tube feeding
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Patient Name Med Record
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If the patient experiment-ADLIADL Deficit - Elimination Deficit - Impaired Mobility
18BCMS 485 (POC)
PatientFamily
NA (Home Health Aide Services not needed)
(SOC)
(M1910) See previous page 13 before the FALL RISK ASSESSMENT
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ALLERGIES MEDICATIONS(M2040) Prior Medication Management Indicate the patients usualability with managing oral and injectable medications prior to this currentillness exacerbation or injury Check only one box in each row
None known NKA AspirinSulfaPollens and mold spores
EggsPenicillin
Insect bitesDairyMilk products
Functional Area Independent NeededSome Help Dependent Not
Applicable
a Oralmedications 0 1 2 na
b Injectablemedications 0 1 2 na
Other
MEDICATIONS
(M2000) Drug Regimen Review Does a complete drug regimen reviewindicate potential clinically significant medication issues eg drugreactions ineffective drug therapy side effects drug interactionsduplicate therapy omissions dosage errors or noncompliance
0 - Not assessedreviewed [Go to M2010]
1 - No problems found during review [Go to M2010]
2 - Problems found during reviewNA - Patient is not taking any medications [Go to M2040]
INFUSION IV THERAPYNA
(M2002) Medication Follow-up Was a physician or the physician-designee contacted within one calendar day to resolve clinicallysignificant medication issues including reconciliation
Peripheral line Central line
Typebrand
0 - No
Size
1 -Yes
Non-tunneledGroshong Non-Groshong TunneledInsertion site Insertion date
(M2010) PatientCaregiver High Risk Drug Education Has the patientcaregiver received instruction on special precautions for all high-riskmedications (such as hypoglycemics anticoagulants etc) and how andwhen to report problems that may occur
Lumens DoubleSingle TripleFlush solution
YesPatent N o
0 - No
Injection cap change frequency
1 -Yes
Dressing change frequency
NA - Patient not taking any high risk drugs OR patientcaregiver fullyknowledgeable about special precautions associated with allhigh-risk medications
Sterile CleanPatient RNPerformed by Caregiver Other
Siteskin condition
(M2020) Management of Oral Medications Patients current ability toprepare and take all oral medications reliably and safely includingadministration of the correct dosage at the appropriate timesintervalsExcludes injectable and IV medications (NOTE This refers to abilitynot compliance or willingness)
External catheter lengthOtherComment
0 - Able to independently take the correct oral medication(s) and
PICC Specific
proper dosage(s) at the correct times
Circumference of arm
1 - Able to take medication(s) at the correct times if
X-ray verificationYes No
(a) individual dosages are prepared in advance by another personOR
IVAD Port Specific
(b) another person develops a drug diary or chart
Reservoir DoubleSingle
2 - Able to take medication(s) at the correct times if given reminders
Huber gaugelength
by another person at the appropriate times
NoAccessed Yes date
3 - Unable to take medication unless administered by another person
EpiduralIntrathecal Access
NA - No oral medications prescribed
Siteskin condition
(M2030) Management of Injectable Medications Patients currentability to prepare and take all prescribed injectable medications reliablyand safely including administration of correct dosage at the appropriatetimesintervals Excludes IV medications
Infusion solution (typevolumerate)DressingOtherComment
0 - Able to independently take the correct medication(s) and properdosage(s) at the correct times
1 - Able to take injectable medication(s) at the correct times if
IV-Infusion Medication(s) administered
(a) individual syringes are prepared in advance by another
Drug Name
person OR
RouteDose
(b) another person develops a drug diary or chart
Frequency Duration of therapy
2 - Able to take medication(s) at the correct times if given remindersby another person based on the frequency of the injection
IV-Infusion Medication(s) administered
3 - Unable to take injectable medication unless administered by
Drug Name
another person
Dose Route
NA - No injectable medications prescribed
Frequency Duration of therapy
Page 15 of 20
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Patient Name Med Record
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Financial ability to pay for medications Yes No
Was MSW referral made Yes
CommentPlan
Infusion IV Therapy order obtained verified
Gauge Length
Frequency
Iodine
Medline catheter
No
- Unsafe Living Environment -Pt demo unsafe behavior or choices - Limited Resources -At risk and lives alone -Pt is CG for another Yes No
Intravenous IV Port Yes No Flush Ordered Yes NoLast flushed date(vascular access device)
IV Therapy complication observed Pain amp irritation Infiltration amp exravasionOcclusionobstruction fluid overload Other
Dust mitesAnimal dander and urine
(SOC)
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INFUSION IV THERAPY (Contd)
Infusion care provided during visitPump (type specify)OtherCaregiverPatient RNAdministered by
Purpose of Intravenous Access
Pain control
Lab drawsInterventions Instructions Comments Problems DetectedAntibiotic therapy
Maintain venous accessChemotherapyParenteral nutrition (TPN)HydrationOther
CARE MANAGEMENT
(M2100) Types and Sources of Assistance Determine the level of caregiver ability and willingness to provide assistance for the following activitiesif assistance is needed (Check only one box in each row)
Caregiver(s)Caregiver(s) Unclear ifNeed TrainingCaregiver(s) AssistanceNo Assistance Not Likely toCurrently Supportive Caregiver(s) Needed ButType of Assistance Needed in This Provide ProvideServices to Will Provide No Caregiver(s)Area Assistance AssistanceAssistance Provide Available
Assistance
a ADL Assistance (egtransferambulation bathingdressing toileting eatingfeeding)
0 1 2 3 4 5
b IADL Assistance (egmeals housekeepinglaundry telephone shoppingfinances)
0 1 2 3 4 5
c Medication Administration(eg oral inhaled orinjectable)
0 1 2 3 4 5
d Medical ProceduresTreatments (eg changingwound dressing)
0 1 2 3 4 5
e Management of Equipment(includes oxygen IVinfusionequipment enteralparenteralnutrition ventilator therapyequipment or supplies)
0 1 2 3 4 5
f Supervision and Safety(eg due to cognitiveimpairment)
0 1 2 3 4 5
g Advocacy or Facilitation ofpatients participation inappropriate medical care(includes transportation to orfrom appointments)
0 1 2 3 4 5
(M2110) How Often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)1 - At least daily 4 - Received but less than weekly
5 - No assistance received2 - Three or more times per weekUK - Unknown3 - One to two times per week
APPLIANCES SPECIAL EQUIPMENT HOME MEDICAL EQUIPMENT Co
Needs (specify)BraceOrthotics (specify)
Bedside commodeTransfer equipment BoardLift Oxygen HME Co
Prosthesis RUE RLE LUELLEOther HME Rep
Grab bars BathroomOther
PhoneOrganizations providing Home Medical Equipment (HME)
Hospital bed Semi-elec Crank SpecLifeline
Page 16 of 20
Patient Name Med Record
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Ostomy Pliers Shower chair Scooters Hoists
Wheeled Walker Other Phone NA
NA
Removing line date (if know)
Expand intravascular volume
Blood and its derivativesNA
NA
NA
(SOC)
SGFire PreventionSafety Program in place Patient instructed
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SAFETY MEASURES LIVING ARRANGEMENTS SUPPORTIVE ASSISTANCE
Oxygen use NYSigns postedYFollow smoking flammables safety precautions N
Oxygen back-up Knows Instructed how to useAvailable
Oxygen Precautions explained
PlanComments
Safety hazards in the home (check all that apply)NYFire alarmsmoke detector Fire extinguish
Inadequate heating cooling electricity lightingHurricane Disaster Emergency supplieskits
NY
InstructionsInformation Provided Sign Up package (Check all that apply)
Y N
Patient Rights and responsibilities
NYFirst aid boxEmergency Equipment or Supplies
State hotlineABUSE number
NYUnsafe gaselectrical appliances or electrical outlets
Advance directives information
NYInadequate running water plumbing problemsDo not resuscitate (DNR) (if applicable)NUnsafe storage of supplies equipment HME
No telephone available andor unable to use the phonePest problems InsectsrodentsMedications stored safely clearly-easy use check interactions
Service AgreementContractNYOASISHIPAA Privacy Notice ConfidentialityNY
Emergency Plan classification instructionsNYAgency phone numbers addressEmergency planning Exit Plan in place more than one exitClient Information Handbook
Y N
Standard precautions handwashing Infection Control
NYEnough Ventilation
Home safety guidelines
Safe BedsChairs clear pathways
Admission criteria Information for Home visit Services FrequencyY NAble to follow directions in case of Emergency
Diabetes Control other disease management informationNYSlippery Floors Ashtrays (if a smoker)
Fall Prevention Program
NYPlan for power failure emergency lights flashlights etc
THERAPY AND PLAN OF CARE(M2200) Therapy Need in the home health plan of care for the Medicarepayment episode for which this assessment will define a case mixgroup what is the indicated need for therapy visits (total of reasonableand necessary physical occupational and speech-language pathologyvisits combined) (Enter zero [000] if no therapy visits indicated)
) Number of therapy visits indicated (total of physicaloccupational and speech-language pathology combined)
(
NA - Not applicable No case mix group defined by this assessment(M2250) Plan of Care Synopsis (Check only one box in each row) Does the physician-ordered plan of care include the following
PlanIntervention YesNo Not Applicable
a Patient-specific parameters for notifying physician ofchanges in vital signs or other clinical findings 0 1 na
Physician has chosen not to establish patient-specific parameters for this patient Agency will usestandardized clinical guidelines accessible for allcare providers to reference
b Diabetic foot care including monitoring for the presence ofskin lesions on the lower extremities and patientcaregivereducation on proper foot care
0 1 naPatient is not diabetic or is bilateral amputee
c Falls prevention interventions 0 1 na Patient is not assessed to be at risk for falls
d Depression intervention(s) such as medication referral forother treatment or a monitoring plan for current treatment 0 1 na Patient has no diagnosis or symptoms of
depression
e Intervention(s) to monitor and mitigate pain 0 1 na No pain identified
f Intervention(s) to prevent pressure ulcers 0 1 na Patient is not assessed to be at risk for pressureulcers
g Pressure ulcer treatment based on principles of moistwound healing OR order for treatment based on moistwound healing has been requested from physician
0 1 naPatient has no pressure ulcers with need for moistwound healing
Page 17 of 20
Y
NY
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Patient Name Med Record
HOME ENVIRONMENT SAFETY
NYRelevant medical appliances if applicable ( wheelchair O2 Monitors etc)NYHurricane Shutter Disaster Plan
Medication sheet reconciliatedchecked
Alzheimers Sensory impairments info
Care Plans
Pain Management info Grievance Procedures
Local Resources Guide Mission ownership information
Physical Therapy Total visitsOccupational Therapy Total visits
Speech Therapy Total visitsOther Therapy Total visits
(SOC)
Safety Measures CMS485 (POC)
Cast PrecautionsChange position slowlyCoumadinHeparin PrecautionsDo not lift bend stoopGood handwashing techniqueOxygen PrecautionFire preventionPractice Universal Precautions
15
Safe Ambulation
Respiratory PrecautionsDiabetic PrecautionsWoundDecubitus precautionsAdequate lightingPrevent Cardiac OverloadPrevent Falls and Injuries GI Precautions
Prev Infection ComplicationsSeizure PrecautionsSuicide precautionsSupport due functional limitationTeach coping skillsSafe storagedisposal syringes Cardiac Precautions
GU Precautions
Safe TransfersSAN PrecautionsCatheter CareProvide Emotional SupportEmergency Plan
Maintain Safeclear EnvironmentMaintain Good Skin care
Clear pathways
Other
SG
Correct handwashing technique SG
Check bathroom floorstairs for safety hazardsPsycho-social behavior precautions
SG
SGSG
SG
SG
SG
Other
SG
SG
SG
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PATIENT CARE COORDINATION
CARE PLAN Reviewed with patient involvementOrder obtainedMedication Form completedreviewedupdated No changeMEDICATION RECORD
Ineffective drug therapySignificant drug interactions
Significant side effectsNon-compliance with drug orders Duplicate drug therapy
Other (specify)M S WSNPhysician AidePT OT STCARE COORDINATION
Explain
Yes No
DME SUPPLIES
IV start kit Underpads size BathbenchChemstrips2x2sIV pole
External catheters
Syringes Cane Quad CaneIV tubing
Urinary bagpouch
COTTON TIP APP4x4s
CommodeAlcohol swabs
Ostomy pouch (brand size)
Special mattress overlayABDs
Angiocatheter size
Cotton tipped applicatorsPeroxide Ostomy wafer (brand size)
Pressure relieving device
Wound cleanserExtension tubingsWound gel
Injection caps
Stoma adhesive tape
Eggcrate
Drain sponges Central line dressing
Skin protectant
Hospital bed
GlovesNon-sterile
Side Rails
Infusion pump Hoyer lift
Sterile Batteries size Enteral feeding pump
Hydrocolloids
Enema suppliesSyringes size
Nebulizer
Kerlix size
Feeding tubeNu-gauze
MEFIX 2X11 YD (EA)
Oxygen concentrator
sizetype Suction machine
SalineNSS
FOLEYCATH SUPPLIES
Suture removal kit Ventilator
Tape
Fr catheter kit
Staple removal kit Walker
(tray bag foley)Transparent dressings
Steri strips
Straight catheter
Wheelchair
Ointment
TRIPLE ANTIBIOTIC 30GR
Irrigation tray
Tens unitSalineNSS
OtherAcetic acid
Other
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Patient Name Med Record
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10
14
PATIENTCAREGIVER INSTRUCTIONS-TEACHINGCheck all that appliesPatientcaregiver(CG) independent with
Trach care
N oYesWoundDecubitus care
Yes No
Yes N o
Ostomy care Yes
N oYesDiabetic managementcare
N o
N oYesNoYesInsulin administration N oYes
Oxygen useprecautions
Yes N oGlucometer usecalibration N oYes
Use of home medical equipmentdevices
N oYesNutritional managementDiet
NoCaregiver present during the visit Yes
PatientCG educationteaching this visit for
N oYesPatientCG able to understand instructionsteaching
Does the patientCG have a plan when disease symptoms exacerbate (eg when to call the nurseAgency vs emergency 911) N oYes
Comment(s)
SKILLED CARE PROVIDED THIS VISIT
Medication management Administration Oral Injection IV-Infused Inhaled
Foley care Yes N o
Pain ManagementHome prescribed exercisesActivities of Daily LivingPersonal Care
MEDICATION
DISEASE PROCESS COMPLICATIONSSS OFILEAL CONDUITOSTOMY SKINFOOT CAREDIET FLUIDS INFECTION CONTROL
OTHER INSTRUCTIONS GIVEN
N oYesElimination Incontinence management
NEEDS FURTHER TEACHINGExplain
NA NANANANANA
NANANANANANANA
Yes N oPhysician follow up visitsappointments NA
Expected Outcome
DISCHARGE PLANNING DISCUSSEDEXPLAINED Patient unable to perform own Wound Care dueto
Patient unable to InsulineInjection self administration dueto
No SO or CG ablewilling for wound careInsulin-Injection administration at this time
Telfa
Colostomy Supplies
Thermometer
Texas Cath
Red Box (Biohazard)
Betadine Solution
Abd Pads
Duoderm
Sharp Container
Ace band size
Leg Straps Cath
ALCOHOL PREP PADS
DUODERM CFGHY-TAPE 2INSERTION TRAY 5CC
INSULIN SYRINGE ____ CCSYRINGES
Glucometer
MICROPORE TAPE 2
SOFTWICK 4X4
VASELINE GAUZE 3X9
KLING 4
(SOC)
Medication Management Check all that appliesidentified Potential adverse effectsdrug reactionsSG
Skil led Observation AssessmentINJECTION ROUTE_______ SITE _____ MED GIVEN ______________________ DOSE __________ REACTION _____________________________
Foley ChangeCare Patient Educationteaching Wound Care Dressing Change Prep Admin Insulin
StandardUniversal Precautions Followed Aseptic Tech Used Quality Control of Glucometer Performed Sharps Discarded Inside Sharps Container
ProcedureTx welltolerated by Pt
Diabetic Observation Care
Correct handwashing technique followed SG ManagementEvaluation Patients Care Plan No caregiverfamily availablewilling to help patient with care procedures
SG
Pshycological carebehaviour problems prevention NA
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Orders by discipline (optional) To complete CMS485 (POC)
SN - ORDERS - FREQUENCYDURATION
Page 19 of 20
Patient Name Med Record
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21
OTHER
General
Psychiatric
F o l e y Care
REPORT ANY ELEVATIONS IN TEMPERATURE TO THE MD
Wound CareDecubitus
IMPROVE THE PTS ABILITY TO PREVENT OR COPE WITH BREATHING DIFFICULTIES
Asthma Respiratory
INST FOR SS EASY FATIGABILITY DYSPNEA PALPITATIONS ANGINA TACHYCARDIAPALLOR DIZZINESS JAUNDICE AND FEVER INST FOR G I DISTURBANCES ASSESS FOR CENTRALNERVOUS SYSTEM SYMPTOMATOLOGY OBTAIN APPROPRIATE LAB TESTS AND REPORT FINDINGS TO MD ADMINISTER PRESCRIBED INJECTABLE _________________ USING ______ TECHNIQUE
Anemia
Included as reference only your Professional Staff must reviewupdatepersonalizedapprove the orders
INSTRUCT IN PREPARATION amp ADMINISTRATION OF INSULIN INSTRUCT ONSET PEAK ampDURATION OF ACTION OF INSULIN INSTRUCT PROPER DISPOSAL OF SYRINGESNEEDLES NURSE TO MONITOR BLOOD SUGAR WITH GLUCOMETER OR ___________ON __________FREQUENCY ampNOTIFY MD OF ALTERED RESULTS TEACH GLUCOMETER OR __________ PROCEDURE amp INTERPRETING RESULTS
InsulinGlucometer
INST DISEASE PROCESS amp COMMON COMPLICATIONS INST PRESCRIBED DIET amp SHOPPING ADVICE INST SSHYPOHYPERGLYCEMIA amp EMERGENCY PROCEDURES INST GOOD SKIN CARE amp GOOD FOOT CARE DAILY CARE OFTEETH INST DIABETIC CHART INST SampA TESTING amp READING RESULTS INSTRUCT TO CARRY ID THAT INCLUDESINFORMATION REGARDING DIABETIC STATUS NAMES amp DOSAGE OF MEDS amp ACTION TO TAKE IF INSULIN REACTION OCCURS INST IMPORTANCE OF GOOD PERSONAL HEALTH HABITS INCLUDING EXERCISE ADEQUATEREST SLEEP REGULAR MED CHECK-UPS (INCLUDING PODIATRIC OPTHAMOLOGIST amp DENTIST)
DiabetesMellitus
INST PACED ACTIVITY PROGRAM
OBSERVE FOR SS OF DECOMPENSATION SUCH AS INCREASING TACHYCARDIA WSUDDEN ONSET SOB ON MINEXERTION ORTHOPNEA EXTREME ANXIETY PROGRESSIVE CYANOSIS GENERALIZED PALLOR AND DIAPHORESISCHF
INSTRUCT PROPER ADMINISTRATION OF OXYGEN THERAPY INSTRUCT OXYGEN PRECAUTIONSINSTRUCT MAINTENANCE OXYGEN EQUIPMENTOxygen
ASSESS FOR CHEST PAIN TYPE LOCATION INTENSITY DURATION amp FREQUENCY IS PAINMANAGEMENT NOTIFY MD IF PAIN PERSISTS IS GRADUAL PROGRESS ACTIVITY INCREASEINST DISCONTINUE ACTIVITY IF CHEST PAIN DYSPNEA FATIGUE OR PALPITATIONS OCCUR
Angina
PSYCHOLOGICAL ASSESSMENT ASSESS NEUROLOGICAL STATUS IMPLEMENT AND MONITOR BOWEL REGIMEN ampTEACH PROGRAM TO FAMILY SN TO MONITOR TRANQUILIZER EFFECTS GIVEN FOR SEVERE AGITATIONANXIETYEVALUATE FOR WEIGHT LOSS WEIGH PATIENT Q VISIT AND RECORDS WEIGHTS MONITOR LEVEL OFCONSCIOUSNESS ASSESS COORDINATION AND BALANCE PROVIDE EMOTIONAL SUPPORT TO PATIENT ANDFAMILY OBSERVATION AND EVALUATION OF BLADDER ELIMINATION HABITS MANAGEMENT IF INCONTINENCEASSIST FAMILY IN SETTING UP ROUTINE PATIENT-CENTERED AND STRESS THE IMPORTANCE OF ADHERING
Alzheimers
AIDE - ORDERS - FREQUENCYDURATIONTUBSHOWER BATH PERSONAL CARE HAIR COMB SHAMPOO PRN MOUTHDENTURE CARE SKIN CHECK ORAL HYGIENE TPRASSIST TO DRESS ASSIST WITH AMBULATION PREPARE SERVE MEALS GROCERY SHOP WASH CLOTHES LIGHT HOUSEKEEPING ASSIST WITH PERSONAL CARE AND ADLSERRANDS NOTIFY LAST BM IF NONE FOR 3 DAYS FEETNAILS CARE PERI CARE REPORT SIGNIFICANT FINDING TO SN STRAIGHTEN ROOM amp CHANGE LINEN
PT - ORDERS - FREQUENCYDURATIONEVALUATE BALANCE AND COORDINATION EVALUATE ENDURANCE MOBILITY NEUROMUSCULAR RE-EDUCATIONPERFORM PRESCRIBED THERAPEUTIC EXERCISES NOTIFY SIGNIFICANT FINDING TO MDAGENCY BED MOBILITY TRAININGGAIT TRAINING WITH ASSISTIVE DEVICE TEACH HOME MAINTENANCE PROGRAM AND STRENGTHENING EXERCISEEXERCISE BOTH PASSIVE AND ACTIVE EXERCISE REGIMEN TRANSFER TRAINING INSTRUCT IN SAFETY MEASURES FALL PRECAUTIONS
OT - ORDERS - FREQUENCYDURATIONEVALUATE PATIENT AND HOME FOR SAFETY ADL TRAINING PROGRAM MUSCLE RE-EDUCATION BODY IMAGE TRAININGINCREASE RIGHT AND LEFT UPPER EXTREMITIES STRENGTH THERAPEUTIC EXERCISE TO (R) AND (L) HANDINCREASE STRENGTH AND COORDINATION PROPRIOCEPTION AND SENSATION
ST FOR EVALUATION TO PROVIDE ORAL MOTOR EXERCISES INVOLVING LINGUAL AND LABIAL EXERCISES SPEECH ARTICULATION DISORDER TREATMENTIMPROVE SPEECH FACIAL SYMMETRY AND MUSCULATION IMPROVE DYSPHAGIA VOICE DISORDER TREATMENT AURAL REHABILITATION NON-ORAL COMMUNICATION LANGUAGE DISORDER TREATMENT
ST - ORDERS - FREQUENCYDURATION
MSW - ORDERS - FREQUENCYDURATIONMSW FOR ASSESSMENT OF SOCIAL AND EMOTIONAL FACTORS COMMUNITY RESOURCE PLANNINGCOUNSELING REGARDING MANAGEMENTADJUSTMENT TO ILLNESS LONG RANGE PLANNING AND DECISION MAKING
PROVIDE SUPPORTIVE AND RELAXATION THERAPY PROVIDE FAMILY THERAPY ASSESS INTERPERSONALBEHAVIOR ASSIST PATIENT TO DEFINE PROBLEMS amp SOCIAL RELATIONSHIPS GIVE POSITIVE REINFORCEMENTASSIST PATIENT TO VERBALIZE FEELINGS
Anxie ty
INST DISEASE PROCESS AND COMMON COMPLICATIONS INST LOW SODIUM DIET - STRESSING IMPORTANCE OFADHERENCE MONITOR PATIENTS BLOOD PRESSURE CLOSELY AND NOTIFY MD OF ANY SIGNIFICANT CHANGESINSTRUCT PT TO AVOID OVER-THE-COUNTER COLD AND SINUS MEDS AS THEY CONTAIN VASOCONSTRICTORINST OF HYPERTENSIVE CRISIS MONITOR FOR SS OF ORTHOSTATIC HYPOTENSION
Hypertension
ASSESS PSYCHOLOGICAL STATUS PROVIDE SUPPORTIVE THERAPY PROVIDE REMOTIVATION ASSESSINTERPERSONAL BEHAVIOR ASSIST PATIENT TO DEFINE PROBLEMS amp SOCIAL RELATIONSHIPS GIVE POSITIVEREINFORCEMENT ENCOURAGE PATIENT TO PERFORM PERSONAL HYGIENE amp GROOMING ACTIVITIESASSIST PATIENT TO EXPRESS REALISTIC IDEAS amp PLANS ASSIST PATIENT TO VERBALIZE FEELINGS
Depression
INSTRUCT PATIENT IN CONSEQUENT PHYSICAL L IMITATIONS PLANNING AN ADEQUATE LEVEL OF DAILYACTIVITIES TEACH PT RE ARTHRITIS SS OF EXACERBATION TEACH THE IMPORTANCE OF GOOD POSTUREPREVENT TRAUMA TO JOINTS INST PT IN THE USE OF ASSISTIVE DEVICE AS PRESCRIBED
Osteoarthritis
SKILLED OBSERVATIONEVALUATION ASSESS VITAL SINGS amp SS COMPLICATIONSINSTRUCTEVALUATE UNDERSTANDING OF DISEASE PROCESS DETECTING COMPLICATIONSDIETNUTRITIONAL STATUS SAFETY PRECAUTIONEMERGENCY MEASURES MED-REGIMEN
PSYCH ASSESSMENT ASSESS FOR SS OF EPSDETECT AND ALLEVIATE SOMATIZED COMPLAINTSLIMIT SETTING MOTIVATION TECHNIQUES IMAGERY TECHNIQUES
RELAXATION TECHNIQUESGOAL ORIENTED TASKS
FOLEY INSERTION _______FR FOLEY WITH___________cc BALLONCHANGE Q MONTH amp PRN x3 FOR CLOGGED LEAKING OR ACCIDENTAL REMOVALINST DRESSING CHANGES ________________________ MONITOR FOR SS COMPLICATIONS amp NOTIFY MD
INST SS INFECTION
MONITOR STATUS OF WOUND OR DECUBITUS (place) ______________INST INFECTION CONTROL MEASURES
INST GOOD NUTRITION TO FACILITATE HEALINGMEASURE AND RECORD WOUND or DECUBITUS SIZE AT SOC AND AT LEAST WEEKLY THEREAFTEROPEN WOUND CAREDRESSING CLEANSE WOUND WITH ___________ TO RINSE WITH __________ AND APPLY______________ AND PRN
OBSERVE AND RECORD TYPE AND AMOUNT OF DRAINAGE COLOR INFECTION SWELLING REDNESS PAINDE CUB ITUS CAR EDR ESS ING CLEAN SE W OUN D WITH ___________ TO R IN SE WITH __________ AN D APP LY ______________ AN D PR N
TEACH THE PATIENT HOW TO USE A METERED-DOSE INHALER MAINTAIN EFFECTIVE AIRWAY CLEARANCE
EMPHASIZE THE IMPORTANCE OF ADEQUATE DAILY FLUID INTAKE
PROMOTE AN EFFICIENT BREATHING PATTER
INST INFECTION CONTROL amp PULMONARY HYGIENE INST COMPLICATIONS IN CARDIOPULMONARY STATUSINST PREVENTION OF COMPLICATIONS IE AVOID OVER-EXERTION CHILLING CROWDS ETC
INST D ISEASE PROCESS amp MAINTENANCE
INSTRUCT COUGHING DEEP BREATHING EXERCISES INST PATIENT TO MAINTAIN ADEQUATE REST PATTERN
MANAGEMENT AND EVALUATION OF A PATIENT CARE PLAN TEACHING AND TRAINING DISEASE PROCESS SKIN CARE WOUND CAREDRESSING CHANGE DECUBITUS CARE MEDICATION REGIMEN DIETNUTRITIONHYDRATION COMPLICATIONS OF ENT FEEDING AS INDICATED
PAIN CONTROL MEASURES SYMPTOM CONTROL MEASURES SINGSSYMPTOMS OF INFECTION SAFETYPREVENTION OF INJURY EMERGENCY PLANS OXYGEN ADMINISTRATION
GeneralSA
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GOALSREHABILITATION POTENTIAL CMS485 (POC)Included as reference only your Professional Staff must reviewupdatepersonalizeapprove the goals
DISCHARGE PLANNING DISCUSSED WITH PATIENT Yes No REHAB POTENTIAL ExcellentPoor Fair Good
SIGNATUREDATES
X DateStaff Completing the OASIS (signaturetitle)
OASIS INFORMATION
Data Entry Date amp Locked Date SubmittedQA Date Reviewed
Page 20 of 20
22
SN - GOALSMRMS _________________ WILL EXHIBIT VITAL SIGNS WITHIN ACCEPTABLE RANGE AND STABILIZED DISEASE PROCESSVERBALIZES KNOWLEDGE OF DISEASE MANAGEMENT MEDICATIONS SIDE EFFECTS PRECAUTIONS DIET FLUIDS TREATMENT PROGRAM SS NECESSITATING MEDICAL ATTENTION EMERGENCY CARE
STABILIZATION OF PSYCHOLOGICAL STATUS WITHIN DISEASE LIMITS TO REDUCE THE PATIENTS ANXIETY LEVELDEPRESIONANXIETY CONTROLED TROUGH MED REGIMEN INTERVENTIONS
ANEMIA CONTROLLED THROUGH MED REGIMEN IMPROVED HEMATOLOGIC STATUS
General
Psychiatric
A n e m i aHEALED WOUND WITHOUT INFECTION OR COMPLICATIONS DEMONSTRATE PROPER WOUND CARE
Wound Care
PTSO SHOULD UNDERSTAND THE NATURE SYMPTOMS STAGE AND PROGRESSION OF ALZHEIMERS DISEASEKNOW HOW TO RECOGNIZE PTS OWN STRESS AND WAYS TO PREVENT OR REDUCE IT PROMOTE SOCIAL INTERACTION AS TOLERATED BY THE PATIENT
Decubitus
DEMONSTRATE STRATEGIES TO BE USED DURING A COUGHING EPISODE HELP THE PATIENT IDENTIFY FACTORSTHAT MAY CAUSE ASTHMA ATTACKS OR CONTRIBUTE TO THEMAsthma
SAFELY ADMINISTERS INJECTION COMPREHEND RATIONALE FOR AND IS ABLE TO ROTATE INJECTION SITESCOMPREHEND SAFETY FACTORS IN SYRINGENEEDLE DISPOSALPATIENTCG ABLE TO MONITOR BLOOD SUGAR CORRECTLY WITHOUT ASSISTANCEABLE TO NOTIFY MD OF ALTEREDOUT OF RANGE RESULTS
InsulinGlucometer
DISCHARGE PT WHEN BLOOD SUGARS ARE WITHIN THE NORMAL FOR PATIENT RANGEKNOW THE ACCEPTABLE RANGE FOR BLOOD SUGAR LEVEL COMPLY WITH DIET RESTRICTIONS Diabetes
MellitusRETURN TO SELF-MANAGEMENT OF HEALED FRACTURED
FractureKNOW ABOUT SIGNS SYMPTOMS AND PRECIPITATING CAUSES OF CHF KNOW HOW TO TAKE THE PULSE AND KNOWTO CONSULT THE DOCTOR BEFORE CONTINUING MEDICATION IF THE PULSE RHYTHM CHANGES KNOW TOA V O I D S M O K I N G A N D S M O K Y E N V I R O N M E N T S A N D P E R S O N S W I T H I N F E C T I O N S E S P E C I A L L Y R E S P I R A T O R Y I N F E C T I O N S
CHF
UNDERSTAND THAT HYPERTENSION IS A CHRONIC DISEASE REQUIRING LIFE LONG TREATMENT EXHIBIT BLOODPRESSURE READINGS CONSISTENTLY WITHIN NORMAL OR SPECIFIED RANGE DEMONSTRATE ADHERENCE TO ALOW-SALT LOW-FAT DIET
Hypertension
HELP THE PATIENT ACHIEVE PAIN RELIEVE AND REDUCE ANGINA EPISODES UNDERSTAND THE CAUSE OFANGINA PECTORIS AND POSSIBLE PRECIPITATING FACTORS FOR AN ATTACK IDENTIFY PERSONAL STRESSORSTHAT MAY CONTRIBUTE TO THE PROBLEM AND BEGIN ELIMINATING OR MINIMIZING THEM KNOW WAYS TOREDUCE THE FREQUENCY OF ANGINA EPISODES
Angina
HEALED DECUBITUS WITHOUT INFECTION OR COMPLICATIONS DEMONSTRATE PROPER DECUBITUS CARE
Alzheimers
UNDERSTAND SS OF BRONCHITIS OR OTHER RESPIRATORY INFECTION AND DISEASE EXACERBATIONUNDERSTAND THE DANGERS OF SMOKING AIR AND CHEMICAL POLLUTANTS AND RESPIRATORY INFECTIONUNDERSTAND AND PRACTICE COUGHING AND DEEP-BREATHING EXERCISES
Respiratory
DAILY COMPLIANCE WCATHETER CARE DECREASE RISK OF URINARY INFECTIONCatheter
INCREASED PAIN RELIEF INCREASED STRENGTH AND ENDURANCE COMPREHEND AND DEMONSTRATE HOME EXERCISEOsteoarthritis
AIDE - GOALS
GAIT PATTERN ENDURANCE STRENGTH AND BALANCE WILL IMPROVE AND PATIENT WILL DEMONSTRATECORRECT BODY MECHANICS WIN 4-6 WKS PTCG WILL COMPREHEND AND DEMONSTRATE HOME EXERCISEPROGRAM WITHIN 4-6 WKS
FAIR-TO BE ABLE TO CARRY OUT MINIMAL ADLS WITH AVAILABLE HOME SUPPORTWILL NOT BE ABLE TO CARRY OUT ADLS WITHOUT MAXIMUM SUPPORT
RETURN TO INDEPENDENT AMBULATION BE SAFE IN SELF CAREPATIENT WILL BE ABLE TO FUNCTION WITH ASSISTANCE OF CAREGIVERWITHIN HESHE CURRENT LIMITATIONS AT HOME
PATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HISHER CURRENT LIMITATIONS AT HOME
PT - GOALS
GOOD RETURN TO PREVIOUS LEVEL OF ADLS INDEPENDENTLY
GAIT PATTERN ENDURANCE STRENGTH AND BALANCE WILL IMPROVE AND PT WILL DEMONSTRATECORRECT BODY MECHANICS WITHIN _____ WEEKS
PATIENT WILL EXPERIENCE A DECREASE IN PAIN
PTCG WILL COMPREHEND AND DEMONSTRATE HOME EXERCISEPROGRAM WITHIN _____ WEEKS
OT PATIENT WILL EXHIBIT IMPROVEMENT IN COPING IN ADLSIADLS MUSCLE USEMOTORCOORDINATIONNEURO RESPONSEUSE OF ORTHOTIC SPLINTING ANDOR EQUIPMENT
OT - GOALS
PATIENT WILL DEMONSTRATE FUNCTIONAL COMMUNICATIONS EXHIBIT MAXIMUM VERBAL AND SENTENCEFORMULATION AND COMPREHENSION WITHIN DISEASE LIMITS WITHIN _____ WEEKS
ST - GOALS
PATIENT WILL DEMONSTRATE APPROPRIATE USE OF FUNCTIONAL VERBALNON-VERBALCOMMUNICATIONS SYSTEMS WITHIN _____ WEEKS
PATIENT WILL DEMONSTRATE IMPROVED READINGWRITING USE OF GESTURESNUMBERS WITHIN _____ WEEKS
PATIENT WILL DEMONSTRATE IMPROVED SWALLOWINGCHEWINGORALMOTOR CONTROL WITHIN _____ WEEKS
PATIENT WILL HAVE ADEQUATE SUPPORT TO REMAIN IN HOME WITH ASSISTANCE OF COMMUNITYRESOURCES FOR FINANCIAL TRANSPORTATION AND PERSONAL CARE ASSISTANCE WITHIN _____ WEEKS
MSW - GOALSPSYCHOSOCIAL EVALUATION WILL BE PERFORMED PTCG WILL BE COUNSELED REGARDING MANAGEMENTamp ADJUSTMENT TO ILLNESS LONG TERM PLANNING AND DECISION MAKING APPROPRIATE COMMUNITYRESOURCE REFERRALS WILL BE MADE
WILL DISCHARGE THE PATIENT WITHIN 60 DAYS WHEN PATIENT ANDORCAREGIVER ISARE ABLE TO DEMONSTRATE KNOWLEDGE OF DISEASE MANAGEMENT SS COMPLICATIONSPATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HISHER CURRENT LIMITATION AT HOME
ABLE TO REMAIN IN HOMERESIDENCEALF WITH ASSISTANCE OF PRIMARY CAEGIVERSUPPORT AT HOMEABLE TO UNDERSTAND MEDICATION REGIMEN AND CARE RELATED TO HISHER DISEASEWILL BE DISCHARGE WHEN MAXIMUM FUNCTIONAL POTENTIAL REACHED
Patient Name Med Record
wwwpnsystemcom 3058185940 The Outcome and Assessment Information Set (OASIS) is the intellectual property of the Center for Health Services and Policy Research Denver Colorado It is used with permission Expiration date 7312012
XPatient Signature if required optional if itinerary is used
SA
LUD
HO
ME
CA
RE
wwwpnsy
stemco
m
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- OASIS_C_SOC
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- PT ID PERFORMED VIA NAME DOB FACE RECOGNITION AND ADDRESS BEFORE SERVICE PROVIDED Off
- TIME IN
- TIME OUT
- Agency Name SALUD HOME CARE INC
- Phone 305-555-5555
- Employees NameTitle Completing the OASIS
- who has signed the plan of care
- Physician name
- Address 1
- Address 2
- Phone Number
- Address 1_2
- Address 2_2
- Patient Phone
- Reason
- Name
- Other Physician if any
- Phone_2
- Address 1_3
- Address 2_3
- Phone Number_2
- REFERRAL SOURCE if not from Primary Physician
- undefined_6
- Phone_3
- Fax
- Evacuation Form needed Emergency Reg 1
- Evacuation Form needed Emergency Reg 2
- EMERGENCY CONTACT
- Address
- Comments 1
- Comments 2
- Phone_4
- Relationship
- OTHER
- Comment 1
- Comment 2
- 11 Other specify
- a
- b
- 7 Other specify
- c
- d
- e
- f
- a_2
- b_2
- d_2
- e_2
- f_2
- a_3
- b_3
- d_3
- Comment if needed 1
- Comment if needed 2
- a_4
- a_5
- a_6
- Date 23
- undefined_7
- undefined_8
- b_4
- b_5
- b_6
- Date_2
- undefined_9
- undefined_10
- Date_3
- undefined_11
- undefined_12
- d_4
- d_5
- d_6
- Date_4
- undefined_13
- undefined_14
- Date_5
- undefined_15
- undefined_16
- Date_6
- undefined_17
- undefined_18
- 12 1
- 12 2
- Date_7
- undefined_19
- undefined_20
- Date_8
- undefined_21
- undefined_22
- MAIN REASON FOR HOME HEALTH CARE 1
- MAIN REASON FOR HOME HEALTH CARE 2
- Fractures site
- Surgeries site
- Cancer site
- Open Wound site
- Decubitus site
- Other specify
- Other
- Pending or Needed
- Yes Number of times
- Reason s Dates
- MobilityAmbulatory devices used
- Other specify_2
- undefined_23
- Comments if needed 1
- Comments if needed 2
- Comments if needed 3
- Comments if needed 4
- undefined_24
- Name_2
- Phone number if different from patient
- Relationshiphealth statusability to help 2
- Any paid help explain
- Specify 1
- Specify 2
- Specify 3
- Any ears surgeryprocedure
- Date_9
- Otherspecify 1
- Otherspecify 2
- Other agencies involved in care 1
- Other agencies involved in care 2
- 1
- 2
- Other_2
- Infections
- Cataract surgery Site
- Date_10
- Other eyes surgery Site
- Date_11
- explain 1
- explain 2
- Any nose surgery
- Date_12
- Other specify_3
- 1_2
- 2_2
- MassesTumors site
- Lesions explain
- Any surgeryprocedure
- Other specify 1
- Other specify 2
- Other specify 3
- Date_13
- Other specify_4
- No Problem
- Medication
- Other_3
- Pain control treatmentmeds Side effect mark
- Other_4
- Is there a regular pattern to the pain explain
- Other_5
- Comment
- What was the outcome
- Type II OnsetExacerbation date
- DietOral control specify
- INSULIN dosage frequency scale explain
- 1_3
- 2_3
- Since
- Other_6
- A1c
- BS
- mgdL DateTime
- Blood sugar ranges
- site 1Location site
- site 2Location site
- site 3Location site
- Frequency
- Other_7
- site 1New Onset Exacerbation
- site 2New Onset Exacerbation
- site 3New Onset Exacerbation
- Able to use Glucometer
- site 1Present level 010
- site 2Present level 010
- site 3Present level 010
- Diabetes Management Problems explain 1
- Diabetes Management Problems explain 2
- Other Endocrine problems
- site 1Occasional y Cont Intermittent Frequency Frequently
- site 2Occasional y Cont Intermittent Frequency Frequently
- site 3Occasional y Cont Intermittent Frequency Frequently
- site 1Pain type ach ng burn ng rad ating neura gia etc
- site 2Pain type ach ng burn ng rad ating neura gia etc
- site 3Pain type ach ng burn ng rad ating neura gia etc
- Anemia specify type if known
- site 1Feeling of pain internal external acute chronic
- site 2Feeling of pain internal external acute chronic
- site 3Feeling of pain internal external acute chronic
- site 1Pain is worse morning
- site 2Pain is worse morning
- site 3Pain is worse morning
- Immunodeficiency problems explain
- Other 1
- Other 2
- Other_8
- explain 1_2
- explain 2_2
- explain 3
- explain 4
- Other specify 1_2
- Other specify 2_2
- undefined_25
- undefined_26
- undefined_27
- undefined_28
- undefined_29
- undefined_30
- undefined_31
- undefined_32
- undefined_33
- undefined_34
- undefined_35
- undefined_36
- M1310 Pressure Ulcer Length Longest length headtotoe
- undefined_37
- cm
- greatest width perpendicular to the length
- M1314 Pressure Ulcer Depth Depth of the same pressure ulcer from
- cm_2
- visible surface to the deepest area
- undefined_38
- cm_3
- 1_4
- 2_4
- 3_2
- Other_9
- 4_2
- Caregiver name
- Other_10
- cant integument findings
- Observation
- Observation_2
- Caregiver name_2
- Other_11
- Wound cleaned with specify
- Wound irrigated with specify
- 1 Size
- cm width
- Wound packed with specify
- Location
- Other_12
- Wound dressingcover applied specify
- 2 Size
- cm width_2
- Comments 1_2
- Comments 2_2
- Location_2
- Other_13
- Sizecm LengthxWidthxDepth
- Sizecm LengthxWidthxDepth_2
- Diagram 4Sizecm LengthxWidthxDepth
- Tunneling Undermining cm
- Tunneling Undermining cm_2
- Diagram 4Tunneling Undermining cm
- Stage IIIIIIIV pressure uIcers only
- Diagram 4Stage IIIIIIIV pressure uIcers only
- Odor Fool normal etc
- Diagram 4Odor Fool normal etc
- Edema pedal sacral p tting etc
- Diagram 4Edema pedal sacral p tting etc
- Appearance of the Wound Bed
- Diagram 4Appearance of the Wound Bed
- Treatment Ordered
- Diagram 4Treatment Ordered
- Other_14
- Other_15
- Other_16
- Other_17
- Yes 1
- Yes 2
- Yes 3
- Height
- Weight
- Radiating to
- GainLoss
- lb X
- Frequencyduration
- Sittinglying R
- L
- Standing R
- L_2
- Medication_2
- Temperature
- Other_18
- Apical
- Brachial
- Radial
- Carotid
- Dependent
- Pitting 1234
- Respirations
- Site
- Cramps site
- Disease Management Problems explain
- Right Upper
- Right
- Right Lower
- 1_5
- 2_6
- 3_3
- Left
- Left Upper
- Left Lower
- Pacemaker Date
- Last date checked
- SOB on minimal effortwalk
- Type
- fy
- Other Prob 1
- Other Prob 2
- O2
- Trach sizetype
- CaregiverfamilyOther
- Yes explain 1
- Yes explain 2
- Other_19
- Comments 1_3
- Comments 2_3
- Increase fluids
- Restrict fluids
- Frequency_2
- Amount
- Yes describe 1
- Yes describe 2
- Frequency_3
- Other 1_2
- Other 2_2
- Nocturia x
- Bowel Off
- undefined_52
- Diapersother
- Other_20
- No
- 2TOTAL
- Urinary Catheter Type
- Last changed on
- Foley inserted date
- with
- Inflated balloon with
- Irrigation solution Type specify
- Amount_2
- mL Frequency
- Returns
- No_2
- 1_6
- 2_7
- Describe at risk intervention and plan 1
- Describe at risk intervention and plan 2
- Describe at risk intervention and plan 3
- DischargeDrainage describe
- Lesions
- Blisters
- Masses
- Cysts
- Wart
- Other specify_5
- Surgical alteration
- Prostate problem BPH TURP Date
- undefined_53
- undefined_54
- Selftesticular exam Frequency
- Hysterectomy Date
- undefined_55
- undefined_56
- Date last PAP
- undefined_57
- undefined_58
- Results
- Breast selfexam frequency
- Mastectomy R L Date
- undefined_59
- undefined_60
- Other specify_6
- Last BM
- Diarrhea Frequency
- Bowel regimeprogram
- Incontinence Off
- Urinary Off
- Diapersother_2
- Other_21
- te describe skin around stoma
- Ileostomycolostomy s 2
- Ileostomycolostomy s 3
- Ileostomycolostomy s 4
- Ileostomycolostomy s 5
- Headache Location
- Frequency_4
- Other_22
- Migraine Frequency
- Site_2
- Weakness UE LE Location
- Other specify_7
- Site_3
- IV
- Pump typespecify
- Hand grips Equal Unequal specify
- Feedings Type amtrate
- Strong Weak specify
- Psychotropic drug use specify
- Flush Protocol amtspecify
- DoseFrequency
- Other_23
- Other specify 1_3
- Other specify 2_3
- DressingSite care specify 1
- DressingSite care specify 2
- Interventions instructionsComments 1
- Interventions instructionsComments 2
- Following Un
- versalStandard precautions
- NA
- No Problem_2
- Pain Frequency
- Abdominal girth
- Bowel sounds active absent hypo hyperactive x
- 3 Forgetful Off
- 4 Depressed Off
- 6 Lethargic Off
- 5 Disoriented Off
- 7 Agitated Off
- 2 Comatose
- 8 Other Off
- Forgetful at times Off
- Irritable Off
- Anxious Off
- Alert Off
- Describe 1
- Describe 2
- undefined_61
- Needs interpreter
- Comments 1_4
- Comments 2_4
- Higher Educational Level
- Fracture location
- Swollen painful joints specify
- Explain
- Contractures Joint
- Spiritual resource
- Location_3
- Phone No
- Atrophy
- Other_27
- Explain 1
- Explain 2
- Decreased ROM
- Paresthesia
- Weakness
- Other_28
- Inappropriate followthrough in past
- Amputation BKAKUE RL specify 1
- Amputation BKAKUE RL specify 3
- Amputation BKAKUE RL specify 4
- Treatment
- Treatment_2
- Other specify 1_4
- Other specify 2_4
- History of Falls past 3 months 12 falls M1032
- V s on Status Poor w or w o glasses M1200
- Vision Status Poor Legally blind M1200
- Gait and Balance Balance problem while standing
- Gait and Ba ance Balance problem while walking
- Gait and Balance Decreased muscular coordination
- Pred spos ng D seases 12 present
- Predisposing D seases 3 or more present
- Equipment Issues Oxygen tubing
- 1Row1
- PlanComments 1
- PlanComments 2
- Comment_2
- undefined_62
- b Ambulation
- c Transfer
- DOther specify
- 7Independent in home 1
- 7Independent in home 2
- Other 1_3
- Other 2_3
- Typebrand
- Size
- Gauge
- Length
- Insertion site
- Insertion date
- Flush solution
- Frequency_5
- Injection cap change frequency
- Dressing change frequency
- Other_29
- Siteskin condition
- External catheter length
- OtherComment
- fluid overload Other
- Circumference of arm
- Huber gaugelength
- Yes date
- Last flushed date
- Siteskin condition_2
- Infusion solution typevolumerate
- Dressing
- OtherComment 1
- OtherComment 2
- Drug Name
- Dose
- Route
- Frequency_6
- Duration of therapy
- Drug Name_2
- Dose_2
- Route_2
- Frequency_7
- Duration of therapy_2
- CommentPlan 1
- CommentPlan 2
- Pump type specify
- Other_30
- Lab draws
- Infusion care provided during visit 1
- Infusion care provided during visit 2
- Infusion care provided during visit 3
- Antibiotic therapy
- 1_7
- 2_8
- Other_31
- Removing line date if know
- BraceOrthotics specify 1
- BraceOrthotics specify 2
- BraceOrthotics specify 3
- Needs specify 1
- Needs specify 2
- Oxygen HME Co
- Prosthesis RUE RLE LUELLEOther
- HME Rep
- Grab bars BathroomOther
- Hospital bed Semielec Crank Spec
- Other_32
- NA_2
- Phone_5
- n care
- PlanComments
- N
- Other_33
- undefined_63
- Physical Therapy Total visits
- Speech Therapy Total visits
- visits
- Other Therapy Total visits
- Patient is not assessed to be at risk for falls
- No pain identified
- Patient has no pressure ulcers with need for moist wound healing
- O
- Noncompliance with drug orders
- Expected Outcome
- Patient unable to perform own Wound Care due
- Pat
- to
- Abd Pads Off
- Underpads size
- undefined_68
- Special mattress overlay
- Angiocatheter size
- Ostomy pouch brand size
- Pressure relieving device
- Ostomy wafer brand size
- undefined_69
- SYRINGES
- Batteries size
- Skin protectant
- Glucometer
- Hydrocolloids
- undefined_70
- FOLEYCATH SUPPLIES
- Syringes size
- size
- Oxygen concentrator
- Feeding tube
- Ointment
- Acetic acid
- Other 1_4
- Other 2_4
- Other 3
- Tens unit
- KLING 4
- Other 1_5
- Other 2_5
- Other 3_2
- PatientCG educationteaching this visit for
- MEDICATION Off
- DISEASE PROCESS COMPLICATIONS Off
- undefined_71
- SS OF Off
- ILEAL CONDUITOSTOMY Off
- DIET FLUIDS Off
- undefined_72
- undefined_73
- SKINFOOT CARE Off
- INFECTION CONTROL Off
- OTHER INSTRUCTIONS GIVEN
- Caregiver present during the visit
- NEEDS FURTHER TEACHING Off
- No_3
- Skilled Observation Assessment
- ent Educat
- Wound Care Dress
- Diabetic Observation Care
- Correct handwashing technique followed SG 1
- Correct handwashing technique followed SG 2
- Correct handwashing technique followed SG 3
- Correct handwashing technique followed SG 4
- 21 Included as reference only your Professional Staff must reviewupdatepersonalizedapprove the orders
- SN ORDERS FREQUENCYDURATION
- S COMPLICATIONS
- TH GLUCOMETER OR
- ON
- TEACH GLUCOMETER OR
- NSERTION
- TH
- INST DRESSING CHANGES
- MONITOR STATUS OF WOUND OR DECUBITUS place
- ADMINISTER PRESCRIBED INJECTABLE
- USING
- TH_2
- TH_3
- AND APPLY
- CLEANSE WOUND WITH
- NSE WITH
- AND APPLY_2
- OTHER_2
- DE ORDERS FREQUENCYDURATION
- PT ORDERS FREQUENCYDURATION
- OT ORDERS FREQUENCYDURATION
- ST ORDERS FREQUENCYDURATION
- MSW ORDERS FREQUENCYDURATION
- Included as reference only your Professional Staff must reviewupdatepersonalizeapprove the goals 22
- MRMS
- PROGRAM WITHIN
- CORRECT BODY MECHANICS WITHIN
- COMMUNICATIONS SYSTEMS WITHIN
- undefined_75
- undefined_76
- Date_14
- QA Date Reviewed
- undefined_77
- undefined_78
- Data Entry Date Locked
- undefined_79
- undefined_80
- Date Submitted
- undefined_81
- undefined_82
- SOCD
- SOCM
- SOCY
- SOCM1
- SOCD1
- SOCY1
- Check Box2 Off
- Check Box3 Off
- Check Box4 Off
- TOM
- TOD
- TOY
- FDM
- FDD
- FDY
- Prov 1071523
- BrID
- Check Box9 Yes
- BrIDno
- Check Box11 Off
- DLCM
- DLCD
- DLCY
- LVM
- LVD
- LVY
- DNR1 Off
- Check Box19 Off
- STFL
- PZC
- MCN
- NOMC Off
- SSN1
- SSN2
- SSN3
- SSUK Off
- MAN
- MAUK Off
- DOBM
- DOBD
- DOBY
- SEX Off
- MR
- First
- MI
- Last
- Suffix
- RACE2 Off
- RACE3 Off
- RACE4 Off
- RACE5 Off
- RACE1 Off
- RACE6 Off
- PS3 Off
- PS0 Off
- PS1 Off
- PS4 Off
- PS5 Off
- PS6 Off
- PS7 Off
- PS8 Off
- PS9 Off
- PS10 Off
- PS11 Off
- PS2 Off
- PSUK Off
- Ecode
- COMP Off
- DACM
- DACD
- DACY
- REA Off
- DM
- DD
- DY
- RDM
- RDD
- RDY
- REFDM
- REFDD
- REFDY
- EPT Off
- 14D2 Off
- 14D3 Off
- 14D4 Off
- 14D5 Off
- 14D6 Off
- 14D7 Off
- 14D8 Off
- Check Box39 Off
- icd9c
- icd9a
- icd9b
- icd9d
- icd9e
- icd9f
- Check Box5 Off
- Check Box7 Off
- icd9b2
- icd9c2
- icd9d2
- C_2
- icd9e2
- icd9f2
- icd9a2
- icd9b3
- icd9c3
- C_3
- icd9a3
- icd9d3
- 1005d
- 1005m
- 1005y
- 1018-2 Off
- 1018-1 Off
- 1018-4 Off
- 1018-5 Off
- 1018-6 Off
- 1018-7 Off
- 1018-NA Off
- 1018-UK Off
- 1018-3 Off
- 1012-na Off
- 1012-uk Off
- Radio Button11 Off
- v1020b
- C_5
- e_5
- f_5
- C_6
- e_6
- f_6
- c_4
- e_4
- f_4
- v1020c
- v1020d
- v1020e
- v1020f
- v1020a
- e1020b
- e1020c
- e1020d
- e1020e
- e1020f
- e1020a
- ev1020b
- ev1020c
- ev1020d
- ev1020e
- ev1020f
- ev1020a
- sp12-1
- sp12-2
- Radio Button12 Off
- Radio Button13 Off
- rad0 Off
- rae0 Off
- rdf0 Off
- phhp Off
- phrp1 Off
- phot1 Off
- phoa1 Off
- phfc1 Off
- phca1 Off
- phin1 Off
- phga1 Off
- phif1 Off
- phsg1 Off
- phwd1 Off
- phdc1 Off
- phgn1 Off
- rddmi Off
- imin Off
- inh1n1 Off
- fwpn Off
- fwtn Off
- fwot Off
- phdm1 Off
- PHNY Off
- phcd1 Off
- 10304 Off
- 10301 Off
- 10302 Off
- 10303 Off
- 10327 Off
- M1034 Off
- HBR1 Off
- HBR2 Off
- HBR3 Off
- HBR4 Off
- HBR5 Off
- HBR6 Off
- HBR7 Off
- HBR8 Off
- HBR9 Off
- HBR11 Off
- HBR12 Off
- HBR10 Off
- HBR13 Off
- SOBFT
- 10321 Off
- 10322 Off
- 10333 Off
- 10324 Off
- 10325 Off
- 10336 Off
- M11001 Off
- M1100b Off
- M1100c Off
- Relationshiphealth statusability to help 1
- 10361 Off
- 10362 Off
- 10363 Off
- 10364 Off
- 10365 Off
- 10366 Off
- 1210d Off
- 1210an Off
- 1210hea Off
- 1210OTH Off
- 1210TIN Off
- 1210NP Off
- 12102 Off
- 12101 Off
- 1210uk Off
- 1210h Off
- 1210v Off
- 1200CAT Off
- 1200OTH Off
- 1200JA Off
- 1200CATRL Off
- 1200OTHER Off
- 1200PT Off
- 1200GLAU Off
- 1200NOP Off
- NOSECON Off
- NOSEEP Off
- NOSELS Off
- NOSESINP Off
- NOSEASG Off
- NOSEOTHSP Off
- NOSENP Off
- THROATDY Off
- TROATL Off
- THROATOTH Off
- 1200BV Off
- 1200LB Off
- THROATHO Off
- THOATSO Off
- THROATNP Off
- 1200GL Off
- 1200CO Off
- 1200PR Off
- 1200IN Off
- M1200 Off
- M1220 Off
- M1230 Off
- MOUTHMas Off
- MOUTHGI Off
- MOUTHULC Off
- MOUTHTOO Off
- MOUTHANY Off
- MOUTHOTH Off
- MOUTHNP Off
- M1240 Off
- M1242 Off
- MOUTHDE Off
- MOUTHUP Off
- MOUTHLO Off
- MOUTHPAR Off
- COPYN Off
- MKMEDP Off
- CPCYN Off
- DPRYN Off
- ICPYN Off
- TURGGP Off
- BESTPAINSC2
- WORSES2
- BESTPAINSC
- WORSESC
- BESTPAINSC3
- WORSESC3
- FACESOBS Off
- SCALE010 Off
- WPSL Off
- WPMA Off
- WPMV Off
- WPAMB Off
- WPIMM Off
- WPTR Off
- WPOTH Off
- WPNP Off
- NVIM Off
- WRP4 Off
- WRP5 Off
- WRP6 Off
- WRP7 Off
- WRP8 Off
- WRP9 Off
- WRPOTH Off
- TKMEDNV Off
- TKMEDLDD Off
- TKMEDD Off
- TKMED23 Off
- TKMEDLT3 Off
- PCTSL Off
- PTXSEN Off
- PTXSEV Off
- PTXSECF Off
- PRDOCC Off
- PTXSEOTH Off
- PRDCONT Off
- WRP1 Off
- WRP2 Off
- WRP3 Off
- PRDINT Off
- PRDFRQ Off
- PHYNOTPT Off
- PHYNOTSTF Off
- NVIG Off
- NVIC Off
- NVIAF Off
- DMIJUV Off
- DMTPII Off
- INSDGFQ Off
- DMODIET Off
- ADMOTH Off
- symphyg Off
- sympfat Off
- symhypog Off
- endopcgr Off
- endopostpra Off
- endorand Off
- endolab Off
- bsrange Off
- bsranptcg Off
- endomonsf Off
- endomoncg Off
- endomonsn Off
- endomonoth Off
- dmNapb Off
- othendopb Off
- enlthyr Off
- intoheatcol Off
- endonp Off
- HEMAANE Off
- HEMABLEED Off
- HEMAHEMO Off
- HEMAINMO Off
- HEMAOTH Off
- HEMANP Off
- SKINITCH Off
- SKINRASH Off
- SKINDRY Off
- SKINSCL Off
- SKINRED Off
- SKINBRU Off
- SKINECCH Off
- SKINPALL Off
- SKINJAU Off
- ADMSELF Off
- ADMSCGF Off
- ADMNURS Off
- SKINNP Off
- m1300 Off
- M1302 Off
- M1306 Off
- M1320 Off
- M1322 Off
- M1324 Off
- M1330 Off
- M1332 Off
- M1334 Off
- M1340 Off
- M1342 Off
- M1350 Off
- WCPYN Off
- IPDMYN Off
- APHYN Off
- SDRBY Off
- SDRSN Off
- SDRCG Off
- SDRPT Off
- SDROTH Off
- TECST Off
- TECCL Off
- WDCLW Off
- WDIRRW Off
- WDPKW Off
- WDDREW Off
- DBFEXD Off
- DBFEX2D Off
- DBFEXEOD Off
- DFEX2WK Off
- DBNFEXWK Off
- DFEXOTH Off
- PDPPRL Off
- PDPARL Off
- LSWRL Off
- endobm Off
- endotv Off
- fbs Off
- LSCDRL Off
- ASCCFR Off
- ASCCFL Off
- Right for
- ASCCFLF
- TRINR Off
- BURRL Off
- LEGHP Off
- LEGHAB Off
- DBFEXRN Off
- DFEXCG Off
- DBFEXPT Off
- DBFEXOT Off
- EXSER Off
- EXSERG Off
- EXSANG Off
- EXSER2 Off
- EXSERG2 Off
- EXSANG2 Off
- SHOV Off
- SHAPRD Off
- SHAPOTH Off
- SHOV2 Off
- SHAPRD2 Off
- SHAPOTH2 Off
- cm length
- cm length2
- DBFTEXRNPT Off
- EXDYN Off
- EXDYN2 Off
- APHYN2 Off
- APHYN3 Off
- Loc3w
- Loc2w
- Loc1w
- Loc4w
- Typew1
- Typew2
- Typew3
- Typw4
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- Edemaw2
- Edemaw3
- appw2
- appw3
- Treatment Ordered_2
- Treatment Ordered_3
- Group10 Off
- draick2 Off
- driack3 Off
- draick4 Off
- colw11 Off
- colw12 Off
- colw31 Off
- colw32 Off
- colw33 Off
- colw34 Off
- colw21 Off
- colw22 Off
- colw23 Off
- colw24 Off
- colw43 Off
- colw44 Off
- ital1u1 Off
- ital1u2 Off
- fsrrepo Off
- frsact Off
- rwgchpt Off
- rwgchcgf Off
- rwgchnur Off
- pulreg1 Off
- pulirreg1 Off
- fsrrespreg Off
- colw41 Off
- colw42 Off
- bpsitly Off
- bpstand Off
- fsrwgrep Off
- fsrwgact Off
- tempaxil Off
- temptymp Off
- pulseappical Off
- pulseradial Off
- pulsebrach Off
- pulsecarot Off
- pulserest Off
- pulsecheyn Off
- pulseactiv Off
- respirirreg Off
- respideath Off
- respaccess Off
- respiapnea Off
- bsckrack Off
- temporal Off
- temprect Off
- chestprad Off
- colw13 Off
- colw14 Off
- consth2 Off
- consthic2 Off
- consth3 Off
- consthic3 Off
- consth4 Off
- consthic4 Off
- chestpyes Off
- chestpainno Off
- consth1 Off
- consthic1 Off
- cpsubstern Off
- cpviselike Off
- dm5lin
- assocwithsoboe Off
- associawactv Off
- associwsweat Off
- cphowreloth Off
- cphowrelrest Off
- cphowrelmeds Off
- cppalarr Off
- cppalpfast Off
- cppalpslow Off
- cppalpfatig Off
- cpedema Off
- cpedemapedal Off
- cpangina Off
- cppostural Off
- cplocalized Off
- cpedempedrig Off
- cpedemapedallef Off
- cpedemasacral Off
- cpedemadepend Off
- cpedemapitt Off
- cpedemanonpitt Off
- cstcramp Off
- cardstclaud Off
- cardstcapref Off
- cstcaprefless Off
- castcaprefgreat Off
- csthsreg Off
- csthsirreg Off
- csthsmurmur Off
- cstpacemak Off
- cpstabreassouclear Off
- breassodwheez Off
- bresddimm Off
- chestpaidull Off
- cpache Off
- cpsharp Off
- brsdabset Off
- brsdsobsoboe Off
- brsdsobonmineff Off
- 14001 Off
- 14003 Off
- 14004 Off
- 1400tva Off
- 14002 Off
- 1400car Off
- 14101 Off
- 14102 Off
- 14103 Off
- 14104 Off
- uroops Off
- uropat Off
- urocare Off
- 14000 Off
- urosn Off
- Radio Button2 Off
- 16100 Off
- 16101 Off
- 1400pat Off
- 16concar Off
- 162gm Off
- 16nas Off
- 16npo Off
- 16102 Off
- 161800cal Off
- 16lowfat Off
- 16lowcho Off
- 16incflu Off
- 16restflu Off
- 16exc Off
- 16good Off
- 16fair Off
- 16poor Off
- 16anore Off
- 16nau Off
- 16vom Off
- 16heabur Off
- O2satur
- O2firesaf Off
- O2sn Off
- O2carefamother Off
- O2cough Off
- O2no Off
- O2yes Off
- O2nonprod Off
- O2noc Off
- O2yesc Off
- O2dys Off
- O2rest Off
- O2dADL Off
- O2sliplo Off
- O2nop Off
- O2yesp Off
- 16other Off
- genibur Off
- genihes Off
- genihema Off
- geniolig Off
- geniurg Off
- geninoc Off
- geniincon Off
- geniuri Off
- genidiap Off
- 16lowna Off
- genicyell Off
- genicamber Off
- genicbr0 Off
- genicbt Off
- genicother Off
- genicla Off
- geniclo Off
- genised Off
- geniodno Off
- genifol Off
- geniwitdif Off
- genisup Off
- geniyes Off
- genino Off
- 1620 Off
- 1615 Off
- 1630 Off
- 1630cosn Off
- 1630lBM Off
- 1630diar Off
- 1630rect Off
- 1630hemo Off
- 1630incon Off
- 1630diap Off
- 1630lax Off
- 1630w Off
- 1630d Off
- 1630m Off
- 1630lleost Off
- 1630pat Off
- 1630car Off
- 1630sn Off
- 1630ot Off
- 1630np Off
- 1630follow Off
- genblis Off
- genmass Off
- gencys Off
- genwart Off
- geninf Off
- gensurg Off
- genprost Off
- gensef Off
- genmeno Off
- genhyst Off
- gendisc Off
- geniodyes Off
- gennp Off
- 1630flat Off
- 17001 Off
- 17002 Off
- 17004 Off
- 1700head Off
- 1700perr Off
- 1700up Off
- 1700apha Off
- 1700rec Off
- 1700exp Off
- 1700mot Off
- 1700gro Off
- 1700dom Off
- 1700weak Off
- 1700trem Off
- 1700fine Off
- 1700gross Off
- 1700paral Off
- 1700stu Off
- 1700halluc Off
- 1700psy Off
- 1700oth Off
- 1700np Off
- EFAD TPN Off
- 17003 Off
- EFAD jej Off
- EFAD iv Off
- EFAD pum Off
- EFDA bol Off
- EFDA con Off
- EFA pat Off
- EFDA sn Off
- EFDA car Off
- EFDAoth Off
- EFDAfu Off
- EFDA na Off
- EFDA np Off
- abd pa Off
- ABD dis Off
- ABD hard Off
- ABD soft Off
- ABD asc Off
- ABD ab Off
- ABD oth Off
- ABD bow Off
- ABD other Off
- ABD ten Off
- EFAD Nas Off
- efad gas Off
- EFAD ot Off
- 17101 Off
- 17102 Off
- 17103 Off
- 17104 Off
- 17105 Off
- 17100 Off
- 1720 Off
- gen dis Off
- genbre Off
- genmast Off
- genoth Off
- 1700fin Off
- 1700mig Off
- genles Off
- 1630 other Off
- 1730 Off
- 1745 Off
- 1750 Off
- 17450 Off
- 1730a Off
- 1730b Off
- 17000 Off
- 17401 Off
- 17402 Off
- 17404 Off
- 17405 Off
- 17406 Off
- 17407 Off
- 1 Oriented Off
- msnp Off
- pslb Off
- psni Off
- psd Off
- psnas Off
- lbm Off
- lbps Off
- lbph Off
- lbf Off
- lbs Off
- urw Off
- sceri Off
- 17403 Off
- ps Off
- ABD pn Off
- pslm Off
- psdp Off
- pspl Off
- psrf Off
- psnh Off
- psue Off
- psir Off
- pse Off
- psep Off
- psea Off
- psvep Off
- psin Off
- psph Off
- psab Off
- psfin Off
- msor Off
- msfr Off
- msre Off
- msp Off
- mssw Off
- mscon Off
- msat Off
- msad Off
- mscan Off
- msuns Off
- mstp Off
- mswal Off
- msdec Off
- par Off
- msot Off
- mssh Off
- mswe Off
- mswea Off
- mskp Off
- msother Off
- mshe Off
- mspa Off
- msqua Off
- msoth Off
- msnop Off
- psina Off
- pssi Off
- psnap Off
- psinap Off
- psan Off
- psfat Off
- pswit Off
- psdif Off
- psdis Off
- psdep Off
- psanx Off
- psnp Off
- psade Off
- psdisc Off
- mscom Off
- msamp Off
- FL2 Off
- FL3 Off
- FL7 Off
- FL8 Off
- FL9 Off
- FLA-d Off
- FLb Off
- FLg Off
- FLart Off
- FLdiz Off
- FLhead Off
- FLins Off
- FLanx Off
- FLsob Off
- FLpoor Off
- FLprod Off
- FLheart Off
- FLp Off
- FLu Off
- FLv Off
- FLed Off
- FLc Off
- FLf Off
- FL1l Off
- FL1b Off
- FL1d Off
- FL1p Off
- FL1li Off
- FL1lr Off
- FL1lc Off
- FL1f Off
- FL1n Off
- FL4 Off
- FL6 Off
- FL5 Off
- adl o Off
- adl 1 Off
- adl 2 Off
- adl 3 Off
- 1810 0 Off
- 1810 1 Off
- 18102 Off
- 18103 Off
- 19100 Off
- 18200 Off
- 18201 Off
- 18202 Off
- 18203 Off
- FL1 Off
- 1910sg Off
- 1910sgp Off
- 1910sgd Off
- 1111910sgp Off
- 1910sgo Off
- 18302 Off
- 18301 Off
- 18300 Off
- 18304 Off
- 18305 Off
- 18306 Off
- 18400 Off
- 18401 Off
- 18402 Off
- 18403 Off
- 18404 Off
- 1910sgpat Off
- 18901 Off
- 18902 Off
- 18903 Off
- 18904 Off
- 18905 Off
- 1890na Off
- adlr Off
- adlna Off
- adlsn Off
- adlm Off
- adlp Off
- adlot Off
- adlst Off
- 18303 Off
- adlcom Off
- 1845 Off
- 1880 Off
- adl Off
- 1850 Off
- 1860 Off
- 1870 Off
- 1900a Off
- 1900b Off
- 1900d Off
- 1900c Off
- 18900 Off
- 19101 Off
- 19102 Off
- 19103 Off
- 19104 Off
- 19105 Off
- 19106 Off
- 19107 Off
- 19108 Off
- 19109 Off
- 1910aw Off
- 1910bw Off
- 1910cnr Off
- 1910do Off
- alleasp Off
- alleggs Off
- alleib Off
- allesulf Off
- allead Off
- alledm Off
- allelod Off
- allepol Off
- alledust Off
- alleother Off
- 20000 Off
- 2000na Off
- 14D1 Off
- 20001 Off
- 20002 Off
- 2010 Off
- 2002 Off
- 2040a Off
- 2040b Off
- 2020 Off
- 2030 Off
- infpat Off
- picccir Off
- ivadacc Off
- int Off
- fo Off
- fa Off
- ule Off
- infiv Off
- perip Off
- mc Off
- gros Off
- tun Off
- nt Off
- ld Off
- lt Off
- cl Off
- pat Off
- rn Off
- cg Off
- ivocc Off
- ivflu Off
- res Off
- red Off
- allerno Off
- iv-i Off
- adp Off
- adc Off
- adrn Off
- adoth Off
- pia Off
- athe Off
- eiv Off
- biood Off
- mva Off
- pn Off
- infna Off
- infcare Off
- rldna Off
- 2100a Off
- 2100b Off
- 2100c Off
- 2100d Off
- 2100e Off
- 2100f Off
- 2100g Off
- 2110 Off
- asheb Off
- ashmet Off
- asehmop Off
- asprost Off
- asebed Off
- aseshow Off
- asescoot Off
- asehoist Off
- asegrab Off
- asehosp Off
- aselif Off
- asewhee Off
- aseoth Off
- aseneed Off
- aseoxy Off
- asefire Off
- aseph Off
- aseorg Off
- asena Off
- smlasa Off
- pump Off
- smcou Off
- smght Off
- smpup Off
- smrp Off
- smwd Off
- smal Off
- smpco Off
- smpfi Off
- smsa Off
- smpic Off
- smsp Off
- smtsc Off
- smsd Off
- smgip Off
- smgup Off
- smst Off
- smcc Off
- smpes Off
- smep Off
- smms Off
- smcp Off
- smcpat Off
- smcht Off
- smcfsh Off
- smpsbp Off
- smoth Off
- oxgava Off
- oxknosw Off
- prr Off
- shan Off
- adi Off
- epci Off
- apn Off
- cih Off
- pmi Off
- sphic Off
- acihsf Off
- dcdmi Off
- dnr Off
- sac Off
- opnc Off
- msr Off
- hsg Off
- asii Off
- gp Off
- fpp Off
- other Off
- pttv Off
- ottv Off
- sttv Off
- ottvist Off
- oxu Off
- oxupe Off
- oufsp Off
- sh Off
- ih Off
- hd Off
- fab Off
- ug Off
- ir Off
- us Off
- nta Off
- pp Off
- mss Off
- ep Off
- ev Off
- sb Off
- adce Off
- sf Off
- ppf Off
- rma Off
- hsd Off
- ppnf Off
- dfc Off
- fpi Off
- dim Off
- imm Off
- ipp Off
- put Off
- cp Off
- ph Off
- sn Off
- ot Off
- st Off
- aid Off
- oth Off
- mfc Off
- nch Off
- oo Off
- mmc Off
- idt Off
- sse Off
- sdi Off
- ncwdo Off
- ddt Off
- eo Off
- no so-cg Off
- nancg Off
- salin Off
- 2x2 Off
- 4x4 Off
- abd Off
- telf Off
- tap Off
- wg Off
- glov Off
- ns Off
- hyd Off
- ks Off
- td Off
- oint Off
- cs Off
- ther Off
- rb Off
- ic Off
- ivsk Off
- ivp Off
- ivt Off
- as Off
- asi Off
- per Off
- et Off
- cid Off
- ip Off
- ss Off
- duo Off
- bs Off
- abs Off
- m2x11 Off
- mt2 Off
- s4x4 Off
- ng Off
- und Off
- ec Off
- ub Off
- op Off
- ow Off
- sat Off
- fol Off
- ls Off
- sc Off
- tc Off
- aa Off
- otth Off
- app Off
- chem Off
- cta Off
- dcfg Off
- hyt Off
- it Off
- syr Off
- glu Off
- es Off
- ft Off
- srk Off
- strk Off
- sstri Off
- is Off
- stst Off
- ta Off
- vg Off
- kl Off
- sr Off
- bath Off
- can Off
- com Off
- smo Off
- prd Off
- egg Off
- hb Off
- hl Off
- efp Off
- neb Off
- oc Off
- pup Off
- pui Off
- or Off
- inj Off
- ivinf Off
- inh Off
- pcbp Off
- fcc Off
- pe Off
- wcd Off
- pai Off
- doc Off
- soa Off
- injr Off
- pt Off
- sup Off
- atu Off
- qc Off
- sd Off
- cht Off
- mep Off
- ncfa Off
- dpd Off
- wdc Off
- dmc Off
- iad Off
- gc Off
- nmd Off
- trc Off
- oca Off
- fc Off
- pfv Off
- oup Off
- uhm Off
- pmh Off
- eim Off
- e911 Off
- puitc Off
- cpdv Off
- dpdp Off
- rp Off
- ko Off
- ipai Off
- iop Off
- iudp Off
- dc Off
- ds Off
- spe Off
- sfcp Off
- ispm Off
- npp Off
- fi Off
- issi Off
- cqm Off
- idc Off
- msw Off
- iicm Off
- ign Off
- ret Off
- mrw Off
- pcd Off
- dccw Off
- ort Off
- epum Off
- meac Off
- pebp Off
- iap Off
- iiph Off
- iccs Off
- ipc Off
- icdb Off
- ipm Off
- ipap Off
- eiad Off
- ipaot Off
- odit Off
- mepc Off
- ttdp Off
- scwc Off
- mr Off
- dn Off
- cef Off
- pcm Off
- si Off
- spi Off
- eplan Off
- oa Off
- nmbs Off
- tg Off
- idp Off
- ipd Off
- icid Off
- igp Off
- ief Off
- ida Off
- nss Off
- api Off
- aps Off
- pst Off
- sib Off
- sdp Off
- ippph Off
- aperi Off
- pf Off
- ap Off
- apv Off
- pa Off
- ans Off
- imb Off
- imt Off
- ewl Off
- acb Off
- mlc Off
- eob Off
- afs Off
- paa Off
- rt Off
- das Off
- got Off
- lsm Off
- dpc Off
- ils Off
- mpb Off
- iao Off
- ihc Off
- mfs Off
- ipcp Off
- tae Off
- iua Off
- tsb Off
- pc Off
- hc Off
- sp Off
- mdc Off
- oh Off
- tpr Off
- ad Off
- awa Off
- psm Off
- gs Off
- wc Off
- lhk Off
- awpc Off
- errand Off
- nlb Off
- fnc Off
- pric Off
- rsf Off
- src Off
- ebc Off
- ppt Off
- gtwa Off
- ebp Off
- eem Off
- nme Off
- nsf Off
- bmt Off
- thm Off
- tt Off
- ism Off
- ephs Off
- irle Off
- isc Off
- atp Off
- mre Off
- te Off
- pas Off
- sfe Off
- pom Off
- sad Off
- isp Off
- fsm Off
- idy Off
- vdt Off
- ar Off
- noc Off
- ldt Off
- mfa Off
- crm Off
- crp Off
- lrp Off
- mrms Off
- sps Off
- acmr Off
- hwi Off
- hdic Off
- psn Off
- dsdc Off
- usb Off
- dcw Off
- saic Off
- dptw Off
- rsm Off
- kss Off
- uhc Off
- hpa Off
- ipi Off
- grp Off
- ftcm Off
- wac Off
- ria Off
- paf Off
- pafi Off
- pwe Off
- ptc Off
- ges Off
- otp Off
- pwdf Off
- pdaf Off
- pdi Off
- pdis Off
- phas Off
- pep Off
- 12100 Off
- allepen Off
- Patient is not diabetic or is bilateral amputee
- mswref Off
- genitonoprob Off
- Urostomy describe skin around stoma Off
- nutrinoprob Off
- O2prod Off
- woraft Off
- woreve Off
- wormor Off
- worsleep Off
- prodsputcol
- fname Off
- Rehabdc1 Off
- mswgwk1
- stgwk2
- stgwk1
- stgwk3
- rhpoor Off
- Clear Form
- E-mail Form
FUNCTIONAL LIMITATIONS ADLIADLs
(M1800) Grooming Current ability to tend safely to personal hygiene7-Ambulationneeds (ie washing face and hands hair care shaving or make up
1 -Amputation
teeth or denture care fingernail care) 2-BowelBladder 8-Speech
0 - Able to groom self unaided with or without the use of assistive(incontinence)
9-Legally blinddevices or adapted methods
3 - Contracture
A -Dyspnea with
1 - Grooming utensils must be placed within reach before able to
4-Hearing
complete grooming activities
B- Other (specify)
5-Paralysis
2 - Someone must assist the patient to groom self
6-Endurance
3 - Patient depends entirely upon someone else for grooming needs
(M1810) Current Ability to Dress Upper Body safely (with or withoutdressing aids) including undergarments pullovers front-opening shirtsand blouses managing zippers buttons and snaps
FALL RISK ASSESSMENT 0 - Able to get clothes out of closets and drawers put them on and
remove them from the upper body without assistance1 - Able to dress upper body without assistance if clothing is laid out
or handed to the patient2 - Someone must help the patient put on upper body clothing3 - Patient depends entirely upon another person to dress the upper
body
(M1830) Bathing Current ability to wash entire body safely Excludes grooming (washing face washing hands and shampooing hair)
1 - With the use of devices is able to bathe self in shower or tubindependently including getting in and out of the tubshower
2 - Able to bathe in shower or tub with the intermittent assistance ofanother person(a) for intermittent supervision or encouragement or reminders
OR(b) to get in and out of the shower or tub OR(c) for washing difficult to reach areas
3 - Able to participate in bathing self in shower or tub but requirespresence of another person throughout the bath for assistance orsupervision
4 - Unable to use the shower or tub but able to bathe selfindependently with or without the use of devices at the sink inchair or on commode
5 - Unable to use the shower or tub but able to participate in bathing
(M1910) Has this patient had a multi-factor Fall Risk Assessment (suchas falls history use of multiple medications mental impairment toiletingfrequency general mobilitytransferring impairment environmentalhazards)
self in bed at the sink in bedside chair or on commode with theassistance or supervision of another person throughout the bath
6 - Unable to participate effectively in bathing and is bathed totally byanother person
0 - No multi-factor falls risk assessment conducted
(M1840) Toilet Transferring Current ability to get to and from the toiletor bedside commode safely and transfer on and off toiletcommode
1 - Yes and it does not indicate a risk for falls2 - Yes and it indicates a risk for falls
0 -Able to get to and from the toilet and transfer independently withor without a device
PlanComments
1 -When reminded assisted or supervised by another person ableto get to and from the toilet and transfer
2 - Unable to get to and from the toilet but is able to use a bedsidecommode (with or without assistance)
3 - Unable to get to and from the toilet or bedside commode but isable to use a bedpanurinal independently
4 - Is totally dependent in toileting
Page 13 of 20
(M1820) Current Ability to Dress Lower Body safely (with or without)dressing aids) including undergarments stacks socks or nylons shoes 0 - Able to obtain put on and remove clothing and shoes without
assistance 1 - Able to dress lower body without assistance if clothing and shoes
are laid out or handed to the patient
2 - Someone must help the patient put on undergarments slackssocks or nylons and shoes
3 - Patient depends entirely upon another person to dress lower body
0 - Able to bathe self in shower or tub independently includinggetting in and our of tubshower
Patient Name Med Record
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18A
Dizziness
Generalized WeaknessArthralgia
InsomniaHeadache
AnxietySOB on exertion
Heartburn
Poor vision
Productive cough
Unsteady GaitPain on ambulation
Varicositis on lower extEdema in __________
Legs weak
Chest pain on exertionFatigues at times
Decreased Bil breath soundsBack Pain
PalpitationsLimited MobilityLimited ROMLeg crampsFreq Coughing episodesNeeds assistance of 1 person
Implement fall precautions for a total score of 10 or greater
Patient Factors Circle appropriate score for each section and total score at bottom (MedQIC) ScoreLevel of Consciousness Mental Status Disoriented X 3 at all times (M1700) 2Level of Consciousness Mental Status Intermittent confusion (M1700 - M1710) 4History of Falls (past 3 months) 1-2 falls (M1032) 2History of Falls (past 3 months) 3 or more falls (M1032) 4Ambulation Elimination Status Chair bound amp requires assist w toileting (M1840) 2Ambulation Elimination Status Ambulatory amp incontinent (M1610 - M1615) 4Vision Status Poor (w or wo glasses) (M1200) 2Vision Status Poor (Legally blind) (M1200)Gait and Balance (Balance problem while standing)Gait and Balance (Balance problem while walking) 1
Gait and Balance (Decreased muscular coordination)
Gait and Balance (Change in gait pattern when walking through doorway) 1Gait and Balance (Jerking or unstable when making turns) 1Gait and Balance (Requires assistance (person furniturewalls or device))
Orthostatic Changes (Droplt20mmHg in BP between lying and standing Increase of cardiac rhythm lt20)
Orthostatic Changes (Drop gt20mmHg in BP between lying and standing Increase of cardiac rhythm gt20)
4
Predisposing Diseases (1-2 present)
Equipment Issues (Oxygen tubing) 1
Total points
4
1
1
2
Medications (Takes 1-2 of these medications currently or win past 7 days)
1
42
Medications (Takes 3-4 of these medications currently or win past 7 days)
Medications (Mark additional point if patient has had a change in these medications or doses in past 5 days) 1
2Predisposing Diseases (3 or more present) 4
Equipment Issues (Inappropriate or client does not consistently use assistive device)
Equipment Issues (Other ) 1
1Equipment Issues (Equipment needs ) 1
Established by the Centers for Medicare amp Medicaid Services (CMS) QualityNet provides healthcare quality improvement news resources and data reporting tools and applications used by healthcare providers and others
Additional service Needed-Impaired Mobility -History of Falls -Predisposing DX - Weakness --Knowledge Deficit or noncompliance with activity restrictions Physical Therapy
Order Obtained
-Unsafe Living Environment -Pt demo unsafe behavior or choices -Limited Resources -At risk and lives alone -Pt is CG for another
Medical Social Services
-ADLIADL Deficits -Sensory Deficits -Decreased Cognition-Unsafe living environment -UE limitations
Occupational Therapy
- - - - - - - -
- - - - - - - -
Certain abilities needed to function independently can be developed or maintained by managing symptoms or through physical or occupational therapy Home health staff needs to evaluate the need for any special assistance devices or equipment and trainpatients on their use If a patient can perform this activity with little assistance they are more independent self-confident and active
If no additional services requested check reasonDiscipline already ordered Pt has been assessed by this discipline win last 30 daysPatientFamily refused additional discipline
QA
(SOC)
SG
No other service approved by Patients Physician
SG
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ADLIADLs (Contd)(M1880) Current Ability to Plan and Prepare Light Meals (eg cerealsandwich) or reheat delivered meals safely
(M1845) Toileting Hygiene Current ability to maintain perineal hygienesafely adjust clothes andor incontinence pads before and after usingtoilet commode bedpan urinal If managing ostomy includes cleaningarea around stoma but not managing equipment
0 - (a) Able to independently plan and prepare all light meals for selfor reheat delivered meals OR
0 - Able to manage toileting hygiene and clothing management (b) Is physically cognitively and mentally able to prepare lightwithout assistance meals on a regular basis but has not routinely performed light
meal preparation in the past (ie prior to this home careadmission)1 - Able to manage toileting hygiene and clothing management
without assistance if suppliesimplements are laid out for the1 - Unable to prepare light meals on a regular basis due to physicalpatient
cognitive or mental limitations2 - Someone must help the patient to maintain toileting hygiene2 - Unable to prepare any light meals or reheat any delivered mealsandor adjust clothing
3 - Patient depends entirely upon another person to maintain toileting(M1890) Ability to Use Telephone Current ability to answer the phonesafely including dialing numbers and effectively using the telephone tocommunicate
hygiene
(M1850) Transferring Current ability to move safely from bed to chairor ability to turn and position self in bed if patient is bedfast 0 - Able to dial numbers and answer calls appropriately and as
desired0 - Able to independently transfer 1 - Able to use a specialty adapted telephone (ie large numbers on
the dial teletype phone for the deaf) and call essential numbers1 -Able to transfer with minimal human assistance or with use of anassistive device 2 - Able to answer the telephone and carry on a normal conversation
but has difficulty with placing calls2 -Able to bear weight and pivot during the transfer process butunable to transfer self 3 - Able to answer the telephone only some of the time or is able to
carry on only a limited conversation3 - Unable to transfer self and is unable to bear weight or pivot when4 - Unable to answer the telephone at all but can listen if assistedtransferred by another person
with equipment4 - Bedfast unable to transfer but is able to turn and position self in5 - Totally unable to use the telephonebed
NA - Patient does not have a telephone5 - Bedfast unable to transfer and is unable to turn and position self
RefusedIndications for Home Health Aide may be needed
(M1860) AmbulationLocomotion Current ability to walk safely oncein a standing position or use a wheelchair once in a seated position ona variety of surfaces
NoYesMD Order obtained
OTSN MSWOther Services ordered STPT
0 - Able to independently walk on even and uneven surfaces and
Comment
negotiate stairs with or without railings (ie needs no humanassistance or assistive device)
1 - With the use of a one-handed device (eg cane single crutchhemi-walker) able to independently walk on even and uneven sur-faces and negotiate stairs with or without railings
2 - Requires use of a two-handed device (eg walker or crutches) to(M1900) Prior Functioning ADLIADL Indicate the patients usualability with everyday activities prior to this current illness exacerbationor injury Check only one box in each row
walk alone on a level surface andor requires human supervisionor assistance to negotiate stairs or steps or uneven surfaces
3 - Able to walk only with the supervision or assistance of another
Functional Area IndependentNeeded
Some HelpDependent
a Self-Care (eg groomingdressing and bathing) 0 1 2
b Ambulation 0 1 2
c Transfer 0 1 2
d Household tasks (eglight meal preparationlaundry shopping)
0
1 2
person at all times
4 - Chairfast unable to ambulate but is able to wheel selfindependently
5 - Chairfast unable to ambulate and is unable to wheel self
6 - Bedfast unable to ambulate or be up in a chair
(M1870) Feeding or Eating Current ability to feed self meals andsnacks safely Note This refers only to the process of eating chewinqand swallowing not preparing the food to be eaten
0 - Able to independently feed self
ACTIVITIES PERMITTED
1 - Able to feed self independently but requires(a) meal set-up OR(b) intermittent assistance or supervision from another person OR(c) a liquid pureed or ground meat diet 8-Crutches1 -Complete bedrest
9-Cane2-BedrestBRP2 -Unable to feed self and must be assisted or supervisedA-Wheelchair3-Up as toleratedthroughout the mealsnackB-Walker4-Transfer bedchair3 - Able to take in nutrients orally and receives supplemental nutrientsC-No restrictions5-Exercises prescribedthrough a nasogastric tube or gastrostomy
D-Other (specify)6-Partial weight bearing4 - Unable to take in nutrients orally and is fed nutrients through anasogastric tube or gastrostomy
7-Independent in home5 - Unable to take in nutrients orally or by tube feeding
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Patient Name Med Record
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If the patient experiment-ADLIADL Deficit - Elimination Deficit - Impaired Mobility
18BCMS 485 (POC)
PatientFamily
NA (Home Health Aide Services not needed)
(SOC)
(M1910) See previous page 13 before the FALL RISK ASSESSMENT
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ALLERGIES MEDICATIONS(M2040) Prior Medication Management Indicate the patients usualability with managing oral and injectable medications prior to this currentillness exacerbation or injury Check only one box in each row
None known NKA AspirinSulfaPollens and mold spores
EggsPenicillin
Insect bitesDairyMilk products
Functional Area Independent NeededSome Help Dependent Not
Applicable
a Oralmedications 0 1 2 na
b Injectablemedications 0 1 2 na
Other
MEDICATIONS
(M2000) Drug Regimen Review Does a complete drug regimen reviewindicate potential clinically significant medication issues eg drugreactions ineffective drug therapy side effects drug interactionsduplicate therapy omissions dosage errors or noncompliance
0 - Not assessedreviewed [Go to M2010]
1 - No problems found during review [Go to M2010]
2 - Problems found during reviewNA - Patient is not taking any medications [Go to M2040]
INFUSION IV THERAPYNA
(M2002) Medication Follow-up Was a physician or the physician-designee contacted within one calendar day to resolve clinicallysignificant medication issues including reconciliation
Peripheral line Central line
Typebrand
0 - No
Size
1 -Yes
Non-tunneledGroshong Non-Groshong TunneledInsertion site Insertion date
(M2010) PatientCaregiver High Risk Drug Education Has the patientcaregiver received instruction on special precautions for all high-riskmedications (such as hypoglycemics anticoagulants etc) and how andwhen to report problems that may occur
Lumens DoubleSingle TripleFlush solution
YesPatent N o
0 - No
Injection cap change frequency
1 -Yes
Dressing change frequency
NA - Patient not taking any high risk drugs OR patientcaregiver fullyknowledgeable about special precautions associated with allhigh-risk medications
Sterile CleanPatient RNPerformed by Caregiver Other
Siteskin condition
(M2020) Management of Oral Medications Patients current ability toprepare and take all oral medications reliably and safely includingadministration of the correct dosage at the appropriate timesintervalsExcludes injectable and IV medications (NOTE This refers to abilitynot compliance or willingness)
External catheter lengthOtherComment
0 - Able to independently take the correct oral medication(s) and
PICC Specific
proper dosage(s) at the correct times
Circumference of arm
1 - Able to take medication(s) at the correct times if
X-ray verificationYes No
(a) individual dosages are prepared in advance by another personOR
IVAD Port Specific
(b) another person develops a drug diary or chart
Reservoir DoubleSingle
2 - Able to take medication(s) at the correct times if given reminders
Huber gaugelength
by another person at the appropriate times
NoAccessed Yes date
3 - Unable to take medication unless administered by another person
EpiduralIntrathecal Access
NA - No oral medications prescribed
Siteskin condition
(M2030) Management of Injectable Medications Patients currentability to prepare and take all prescribed injectable medications reliablyand safely including administration of correct dosage at the appropriatetimesintervals Excludes IV medications
Infusion solution (typevolumerate)DressingOtherComment
0 - Able to independently take the correct medication(s) and properdosage(s) at the correct times
1 - Able to take injectable medication(s) at the correct times if
IV-Infusion Medication(s) administered
(a) individual syringes are prepared in advance by another
Drug Name
person OR
RouteDose
(b) another person develops a drug diary or chart
Frequency Duration of therapy
2 - Able to take medication(s) at the correct times if given remindersby another person based on the frequency of the injection
IV-Infusion Medication(s) administered
3 - Unable to take injectable medication unless administered by
Drug Name
another person
Dose Route
NA - No injectable medications prescribed
Frequency Duration of therapy
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Patient Name Med Record
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Financial ability to pay for medications Yes No
Was MSW referral made Yes
CommentPlan
Infusion IV Therapy order obtained verified
Gauge Length
Frequency
Iodine
Medline catheter
No
- Unsafe Living Environment -Pt demo unsafe behavior or choices - Limited Resources -At risk and lives alone -Pt is CG for another Yes No
Intravenous IV Port Yes No Flush Ordered Yes NoLast flushed date(vascular access device)
IV Therapy complication observed Pain amp irritation Infiltration amp exravasionOcclusionobstruction fluid overload Other
Dust mitesAnimal dander and urine
(SOC)
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INFUSION IV THERAPY (Contd)
Infusion care provided during visitPump (type specify)OtherCaregiverPatient RNAdministered by
Purpose of Intravenous Access
Pain control
Lab drawsInterventions Instructions Comments Problems DetectedAntibiotic therapy
Maintain venous accessChemotherapyParenteral nutrition (TPN)HydrationOther
CARE MANAGEMENT
(M2100) Types and Sources of Assistance Determine the level of caregiver ability and willingness to provide assistance for the following activitiesif assistance is needed (Check only one box in each row)
Caregiver(s)Caregiver(s) Unclear ifNeed TrainingCaregiver(s) AssistanceNo Assistance Not Likely toCurrently Supportive Caregiver(s) Needed ButType of Assistance Needed in This Provide ProvideServices to Will Provide No Caregiver(s)Area Assistance AssistanceAssistance Provide Available
Assistance
a ADL Assistance (egtransferambulation bathingdressing toileting eatingfeeding)
0 1 2 3 4 5
b IADL Assistance (egmeals housekeepinglaundry telephone shoppingfinances)
0 1 2 3 4 5
c Medication Administration(eg oral inhaled orinjectable)
0 1 2 3 4 5
d Medical ProceduresTreatments (eg changingwound dressing)
0 1 2 3 4 5
e Management of Equipment(includes oxygen IVinfusionequipment enteralparenteralnutrition ventilator therapyequipment or supplies)
0 1 2 3 4 5
f Supervision and Safety(eg due to cognitiveimpairment)
0 1 2 3 4 5
g Advocacy or Facilitation ofpatients participation inappropriate medical care(includes transportation to orfrom appointments)
0 1 2 3 4 5
(M2110) How Often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)1 - At least daily 4 - Received but less than weekly
5 - No assistance received2 - Three or more times per weekUK - Unknown3 - One to two times per week
APPLIANCES SPECIAL EQUIPMENT HOME MEDICAL EQUIPMENT Co
Needs (specify)BraceOrthotics (specify)
Bedside commodeTransfer equipment BoardLift Oxygen HME Co
Prosthesis RUE RLE LUELLEOther HME Rep
Grab bars BathroomOther
PhoneOrganizations providing Home Medical Equipment (HME)
Hospital bed Semi-elec Crank SpecLifeline
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Patient Name Med Record
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Ostomy Pliers Shower chair Scooters Hoists
Wheeled Walker Other Phone NA
NA
Removing line date (if know)
Expand intravascular volume
Blood and its derivativesNA
NA
NA
(SOC)
SGFire PreventionSafety Program in place Patient instructed
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SAFETY MEASURES LIVING ARRANGEMENTS SUPPORTIVE ASSISTANCE
Oxygen use NYSigns postedYFollow smoking flammables safety precautions N
Oxygen back-up Knows Instructed how to useAvailable
Oxygen Precautions explained
PlanComments
Safety hazards in the home (check all that apply)NYFire alarmsmoke detector Fire extinguish
Inadequate heating cooling electricity lightingHurricane Disaster Emergency supplieskits
NY
InstructionsInformation Provided Sign Up package (Check all that apply)
Y N
Patient Rights and responsibilities
NYFirst aid boxEmergency Equipment or Supplies
State hotlineABUSE number
NYUnsafe gaselectrical appliances or electrical outlets
Advance directives information
NYInadequate running water plumbing problemsDo not resuscitate (DNR) (if applicable)NUnsafe storage of supplies equipment HME
No telephone available andor unable to use the phonePest problems InsectsrodentsMedications stored safely clearly-easy use check interactions
Service AgreementContractNYOASISHIPAA Privacy Notice ConfidentialityNY
Emergency Plan classification instructionsNYAgency phone numbers addressEmergency planning Exit Plan in place more than one exitClient Information Handbook
Y N
Standard precautions handwashing Infection Control
NYEnough Ventilation
Home safety guidelines
Safe BedsChairs clear pathways
Admission criteria Information for Home visit Services FrequencyY NAble to follow directions in case of Emergency
Diabetes Control other disease management informationNYSlippery Floors Ashtrays (if a smoker)
Fall Prevention Program
NYPlan for power failure emergency lights flashlights etc
THERAPY AND PLAN OF CARE(M2200) Therapy Need in the home health plan of care for the Medicarepayment episode for which this assessment will define a case mixgroup what is the indicated need for therapy visits (total of reasonableand necessary physical occupational and speech-language pathologyvisits combined) (Enter zero [000] if no therapy visits indicated)
) Number of therapy visits indicated (total of physicaloccupational and speech-language pathology combined)
(
NA - Not applicable No case mix group defined by this assessment(M2250) Plan of Care Synopsis (Check only one box in each row) Does the physician-ordered plan of care include the following
PlanIntervention YesNo Not Applicable
a Patient-specific parameters for notifying physician ofchanges in vital signs or other clinical findings 0 1 na
Physician has chosen not to establish patient-specific parameters for this patient Agency will usestandardized clinical guidelines accessible for allcare providers to reference
b Diabetic foot care including monitoring for the presence ofskin lesions on the lower extremities and patientcaregivereducation on proper foot care
0 1 naPatient is not diabetic or is bilateral amputee
c Falls prevention interventions 0 1 na Patient is not assessed to be at risk for falls
d Depression intervention(s) such as medication referral forother treatment or a monitoring plan for current treatment 0 1 na Patient has no diagnosis or symptoms of
depression
e Intervention(s) to monitor and mitigate pain 0 1 na No pain identified
f Intervention(s) to prevent pressure ulcers 0 1 na Patient is not assessed to be at risk for pressureulcers
g Pressure ulcer treatment based on principles of moistwound healing OR order for treatment based on moistwound healing has been requested from physician
0 1 naPatient has no pressure ulcers with need for moistwound healing
Page 17 of 20
Y
NY
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Patient Name Med Record
HOME ENVIRONMENT SAFETY
NYRelevant medical appliances if applicable ( wheelchair O2 Monitors etc)NYHurricane Shutter Disaster Plan
Medication sheet reconciliatedchecked
Alzheimers Sensory impairments info
Care Plans
Pain Management info Grievance Procedures
Local Resources Guide Mission ownership information
Physical Therapy Total visitsOccupational Therapy Total visits
Speech Therapy Total visitsOther Therapy Total visits
(SOC)
Safety Measures CMS485 (POC)
Cast PrecautionsChange position slowlyCoumadinHeparin PrecautionsDo not lift bend stoopGood handwashing techniqueOxygen PrecautionFire preventionPractice Universal Precautions
15
Safe Ambulation
Respiratory PrecautionsDiabetic PrecautionsWoundDecubitus precautionsAdequate lightingPrevent Cardiac OverloadPrevent Falls and Injuries GI Precautions
Prev Infection ComplicationsSeizure PrecautionsSuicide precautionsSupport due functional limitationTeach coping skillsSafe storagedisposal syringes Cardiac Precautions
GU Precautions
Safe TransfersSAN PrecautionsCatheter CareProvide Emotional SupportEmergency Plan
Maintain Safeclear EnvironmentMaintain Good Skin care
Clear pathways
Other
SG
Correct handwashing technique SG
Check bathroom floorstairs for safety hazardsPsycho-social behavior precautions
SG
SGSG
SG
SG
SG
Other
SG
SG
SG
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PATIENT CARE COORDINATION
CARE PLAN Reviewed with patient involvementOrder obtainedMedication Form completedreviewedupdated No changeMEDICATION RECORD
Ineffective drug therapySignificant drug interactions
Significant side effectsNon-compliance with drug orders Duplicate drug therapy
Other (specify)M S WSNPhysician AidePT OT STCARE COORDINATION
Explain
Yes No
DME SUPPLIES
IV start kit Underpads size BathbenchChemstrips2x2sIV pole
External catheters
Syringes Cane Quad CaneIV tubing
Urinary bagpouch
COTTON TIP APP4x4s
CommodeAlcohol swabs
Ostomy pouch (brand size)
Special mattress overlayABDs
Angiocatheter size
Cotton tipped applicatorsPeroxide Ostomy wafer (brand size)
Pressure relieving device
Wound cleanserExtension tubingsWound gel
Injection caps
Stoma adhesive tape
Eggcrate
Drain sponges Central line dressing
Skin protectant
Hospital bed
GlovesNon-sterile
Side Rails
Infusion pump Hoyer lift
Sterile Batteries size Enteral feeding pump
Hydrocolloids
Enema suppliesSyringes size
Nebulizer
Kerlix size
Feeding tubeNu-gauze
MEFIX 2X11 YD (EA)
Oxygen concentrator
sizetype Suction machine
SalineNSS
FOLEYCATH SUPPLIES
Suture removal kit Ventilator
Tape
Fr catheter kit
Staple removal kit Walker
(tray bag foley)Transparent dressings
Steri strips
Straight catheter
Wheelchair
Ointment
TRIPLE ANTIBIOTIC 30GR
Irrigation tray
Tens unitSalineNSS
OtherAcetic acid
Other
Page 18 of 20
Patient Name Med Record
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10
14
PATIENTCAREGIVER INSTRUCTIONS-TEACHINGCheck all that appliesPatientcaregiver(CG) independent with
Trach care
N oYesWoundDecubitus care
Yes No
Yes N o
Ostomy care Yes
N oYesDiabetic managementcare
N o
N oYesNoYesInsulin administration N oYes
Oxygen useprecautions
Yes N oGlucometer usecalibration N oYes
Use of home medical equipmentdevices
N oYesNutritional managementDiet
NoCaregiver present during the visit Yes
PatientCG educationteaching this visit for
N oYesPatientCG able to understand instructionsteaching
Does the patientCG have a plan when disease symptoms exacerbate (eg when to call the nurseAgency vs emergency 911) N oYes
Comment(s)
SKILLED CARE PROVIDED THIS VISIT
Medication management Administration Oral Injection IV-Infused Inhaled
Foley care Yes N o
Pain ManagementHome prescribed exercisesActivities of Daily LivingPersonal Care
MEDICATION
DISEASE PROCESS COMPLICATIONSSS OFILEAL CONDUITOSTOMY SKINFOOT CAREDIET FLUIDS INFECTION CONTROL
OTHER INSTRUCTIONS GIVEN
N oYesElimination Incontinence management
NEEDS FURTHER TEACHINGExplain
NA NANANANANA
NANANANANANANA
Yes N oPhysician follow up visitsappointments NA
Expected Outcome
DISCHARGE PLANNING DISCUSSEDEXPLAINED Patient unable to perform own Wound Care dueto
Patient unable to InsulineInjection self administration dueto
No SO or CG ablewilling for wound careInsulin-Injection administration at this time
Telfa
Colostomy Supplies
Thermometer
Texas Cath
Red Box (Biohazard)
Betadine Solution
Abd Pads
Duoderm
Sharp Container
Ace band size
Leg Straps Cath
ALCOHOL PREP PADS
DUODERM CFGHY-TAPE 2INSERTION TRAY 5CC
INSULIN SYRINGE ____ CCSYRINGES
Glucometer
MICROPORE TAPE 2
SOFTWICK 4X4
VASELINE GAUZE 3X9
KLING 4
(SOC)
Medication Management Check all that appliesidentified Potential adverse effectsdrug reactionsSG
Skil led Observation AssessmentINJECTION ROUTE_______ SITE _____ MED GIVEN ______________________ DOSE __________ REACTION _____________________________
Foley ChangeCare Patient Educationteaching Wound Care Dressing Change Prep Admin Insulin
StandardUniversal Precautions Followed Aseptic Tech Used Quality Control of Glucometer Performed Sharps Discarded Inside Sharps Container
ProcedureTx welltolerated by Pt
Diabetic Observation Care
Correct handwashing technique followed SG ManagementEvaluation Patients Care Plan No caregiverfamily availablewilling to help patient with care procedures
SG
Pshycological carebehaviour problems prevention NA
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Orders by discipline (optional) To complete CMS485 (POC)
SN - ORDERS - FREQUENCYDURATION
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Patient Name Med Record
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21
OTHER
General
Psychiatric
F o l e y Care
REPORT ANY ELEVATIONS IN TEMPERATURE TO THE MD
Wound CareDecubitus
IMPROVE THE PTS ABILITY TO PREVENT OR COPE WITH BREATHING DIFFICULTIES
Asthma Respiratory
INST FOR SS EASY FATIGABILITY DYSPNEA PALPITATIONS ANGINA TACHYCARDIAPALLOR DIZZINESS JAUNDICE AND FEVER INST FOR G I DISTURBANCES ASSESS FOR CENTRALNERVOUS SYSTEM SYMPTOMATOLOGY OBTAIN APPROPRIATE LAB TESTS AND REPORT FINDINGS TO MD ADMINISTER PRESCRIBED INJECTABLE _________________ USING ______ TECHNIQUE
Anemia
Included as reference only your Professional Staff must reviewupdatepersonalizedapprove the orders
INSTRUCT IN PREPARATION amp ADMINISTRATION OF INSULIN INSTRUCT ONSET PEAK ampDURATION OF ACTION OF INSULIN INSTRUCT PROPER DISPOSAL OF SYRINGESNEEDLES NURSE TO MONITOR BLOOD SUGAR WITH GLUCOMETER OR ___________ON __________FREQUENCY ampNOTIFY MD OF ALTERED RESULTS TEACH GLUCOMETER OR __________ PROCEDURE amp INTERPRETING RESULTS
InsulinGlucometer
INST DISEASE PROCESS amp COMMON COMPLICATIONS INST PRESCRIBED DIET amp SHOPPING ADVICE INST SSHYPOHYPERGLYCEMIA amp EMERGENCY PROCEDURES INST GOOD SKIN CARE amp GOOD FOOT CARE DAILY CARE OFTEETH INST DIABETIC CHART INST SampA TESTING amp READING RESULTS INSTRUCT TO CARRY ID THAT INCLUDESINFORMATION REGARDING DIABETIC STATUS NAMES amp DOSAGE OF MEDS amp ACTION TO TAKE IF INSULIN REACTION OCCURS INST IMPORTANCE OF GOOD PERSONAL HEALTH HABITS INCLUDING EXERCISE ADEQUATEREST SLEEP REGULAR MED CHECK-UPS (INCLUDING PODIATRIC OPTHAMOLOGIST amp DENTIST)
DiabetesMellitus
INST PACED ACTIVITY PROGRAM
OBSERVE FOR SS OF DECOMPENSATION SUCH AS INCREASING TACHYCARDIA WSUDDEN ONSET SOB ON MINEXERTION ORTHOPNEA EXTREME ANXIETY PROGRESSIVE CYANOSIS GENERALIZED PALLOR AND DIAPHORESISCHF
INSTRUCT PROPER ADMINISTRATION OF OXYGEN THERAPY INSTRUCT OXYGEN PRECAUTIONSINSTRUCT MAINTENANCE OXYGEN EQUIPMENTOxygen
ASSESS FOR CHEST PAIN TYPE LOCATION INTENSITY DURATION amp FREQUENCY IS PAINMANAGEMENT NOTIFY MD IF PAIN PERSISTS IS GRADUAL PROGRESS ACTIVITY INCREASEINST DISCONTINUE ACTIVITY IF CHEST PAIN DYSPNEA FATIGUE OR PALPITATIONS OCCUR
Angina
PSYCHOLOGICAL ASSESSMENT ASSESS NEUROLOGICAL STATUS IMPLEMENT AND MONITOR BOWEL REGIMEN ampTEACH PROGRAM TO FAMILY SN TO MONITOR TRANQUILIZER EFFECTS GIVEN FOR SEVERE AGITATIONANXIETYEVALUATE FOR WEIGHT LOSS WEIGH PATIENT Q VISIT AND RECORDS WEIGHTS MONITOR LEVEL OFCONSCIOUSNESS ASSESS COORDINATION AND BALANCE PROVIDE EMOTIONAL SUPPORT TO PATIENT ANDFAMILY OBSERVATION AND EVALUATION OF BLADDER ELIMINATION HABITS MANAGEMENT IF INCONTINENCEASSIST FAMILY IN SETTING UP ROUTINE PATIENT-CENTERED AND STRESS THE IMPORTANCE OF ADHERING
Alzheimers
AIDE - ORDERS - FREQUENCYDURATIONTUBSHOWER BATH PERSONAL CARE HAIR COMB SHAMPOO PRN MOUTHDENTURE CARE SKIN CHECK ORAL HYGIENE TPRASSIST TO DRESS ASSIST WITH AMBULATION PREPARE SERVE MEALS GROCERY SHOP WASH CLOTHES LIGHT HOUSEKEEPING ASSIST WITH PERSONAL CARE AND ADLSERRANDS NOTIFY LAST BM IF NONE FOR 3 DAYS FEETNAILS CARE PERI CARE REPORT SIGNIFICANT FINDING TO SN STRAIGHTEN ROOM amp CHANGE LINEN
PT - ORDERS - FREQUENCYDURATIONEVALUATE BALANCE AND COORDINATION EVALUATE ENDURANCE MOBILITY NEUROMUSCULAR RE-EDUCATIONPERFORM PRESCRIBED THERAPEUTIC EXERCISES NOTIFY SIGNIFICANT FINDING TO MDAGENCY BED MOBILITY TRAININGGAIT TRAINING WITH ASSISTIVE DEVICE TEACH HOME MAINTENANCE PROGRAM AND STRENGTHENING EXERCISEEXERCISE BOTH PASSIVE AND ACTIVE EXERCISE REGIMEN TRANSFER TRAINING INSTRUCT IN SAFETY MEASURES FALL PRECAUTIONS
OT - ORDERS - FREQUENCYDURATIONEVALUATE PATIENT AND HOME FOR SAFETY ADL TRAINING PROGRAM MUSCLE RE-EDUCATION BODY IMAGE TRAININGINCREASE RIGHT AND LEFT UPPER EXTREMITIES STRENGTH THERAPEUTIC EXERCISE TO (R) AND (L) HANDINCREASE STRENGTH AND COORDINATION PROPRIOCEPTION AND SENSATION
ST FOR EVALUATION TO PROVIDE ORAL MOTOR EXERCISES INVOLVING LINGUAL AND LABIAL EXERCISES SPEECH ARTICULATION DISORDER TREATMENTIMPROVE SPEECH FACIAL SYMMETRY AND MUSCULATION IMPROVE DYSPHAGIA VOICE DISORDER TREATMENT AURAL REHABILITATION NON-ORAL COMMUNICATION LANGUAGE DISORDER TREATMENT
ST - ORDERS - FREQUENCYDURATION
MSW - ORDERS - FREQUENCYDURATIONMSW FOR ASSESSMENT OF SOCIAL AND EMOTIONAL FACTORS COMMUNITY RESOURCE PLANNINGCOUNSELING REGARDING MANAGEMENTADJUSTMENT TO ILLNESS LONG RANGE PLANNING AND DECISION MAKING
PROVIDE SUPPORTIVE AND RELAXATION THERAPY PROVIDE FAMILY THERAPY ASSESS INTERPERSONALBEHAVIOR ASSIST PATIENT TO DEFINE PROBLEMS amp SOCIAL RELATIONSHIPS GIVE POSITIVE REINFORCEMENTASSIST PATIENT TO VERBALIZE FEELINGS
Anxie ty
INST DISEASE PROCESS AND COMMON COMPLICATIONS INST LOW SODIUM DIET - STRESSING IMPORTANCE OFADHERENCE MONITOR PATIENTS BLOOD PRESSURE CLOSELY AND NOTIFY MD OF ANY SIGNIFICANT CHANGESINSTRUCT PT TO AVOID OVER-THE-COUNTER COLD AND SINUS MEDS AS THEY CONTAIN VASOCONSTRICTORINST OF HYPERTENSIVE CRISIS MONITOR FOR SS OF ORTHOSTATIC HYPOTENSION
Hypertension
ASSESS PSYCHOLOGICAL STATUS PROVIDE SUPPORTIVE THERAPY PROVIDE REMOTIVATION ASSESSINTERPERSONAL BEHAVIOR ASSIST PATIENT TO DEFINE PROBLEMS amp SOCIAL RELATIONSHIPS GIVE POSITIVEREINFORCEMENT ENCOURAGE PATIENT TO PERFORM PERSONAL HYGIENE amp GROOMING ACTIVITIESASSIST PATIENT TO EXPRESS REALISTIC IDEAS amp PLANS ASSIST PATIENT TO VERBALIZE FEELINGS
Depression
INSTRUCT PATIENT IN CONSEQUENT PHYSICAL L IMITATIONS PLANNING AN ADEQUATE LEVEL OF DAILYACTIVITIES TEACH PT RE ARTHRITIS SS OF EXACERBATION TEACH THE IMPORTANCE OF GOOD POSTUREPREVENT TRAUMA TO JOINTS INST PT IN THE USE OF ASSISTIVE DEVICE AS PRESCRIBED
Osteoarthritis
SKILLED OBSERVATIONEVALUATION ASSESS VITAL SINGS amp SS COMPLICATIONSINSTRUCTEVALUATE UNDERSTANDING OF DISEASE PROCESS DETECTING COMPLICATIONSDIETNUTRITIONAL STATUS SAFETY PRECAUTIONEMERGENCY MEASURES MED-REGIMEN
PSYCH ASSESSMENT ASSESS FOR SS OF EPSDETECT AND ALLEVIATE SOMATIZED COMPLAINTSLIMIT SETTING MOTIVATION TECHNIQUES IMAGERY TECHNIQUES
RELAXATION TECHNIQUESGOAL ORIENTED TASKS
FOLEY INSERTION _______FR FOLEY WITH___________cc BALLONCHANGE Q MONTH amp PRN x3 FOR CLOGGED LEAKING OR ACCIDENTAL REMOVALINST DRESSING CHANGES ________________________ MONITOR FOR SS COMPLICATIONS amp NOTIFY MD
INST SS INFECTION
MONITOR STATUS OF WOUND OR DECUBITUS (place) ______________INST INFECTION CONTROL MEASURES
INST GOOD NUTRITION TO FACILITATE HEALINGMEASURE AND RECORD WOUND or DECUBITUS SIZE AT SOC AND AT LEAST WEEKLY THEREAFTEROPEN WOUND CAREDRESSING CLEANSE WOUND WITH ___________ TO RINSE WITH __________ AND APPLY______________ AND PRN
OBSERVE AND RECORD TYPE AND AMOUNT OF DRAINAGE COLOR INFECTION SWELLING REDNESS PAINDE CUB ITUS CAR EDR ESS ING CLEAN SE W OUN D WITH ___________ TO R IN SE WITH __________ AN D APP LY ______________ AN D PR N
TEACH THE PATIENT HOW TO USE A METERED-DOSE INHALER MAINTAIN EFFECTIVE AIRWAY CLEARANCE
EMPHASIZE THE IMPORTANCE OF ADEQUATE DAILY FLUID INTAKE
PROMOTE AN EFFICIENT BREATHING PATTER
INST INFECTION CONTROL amp PULMONARY HYGIENE INST COMPLICATIONS IN CARDIOPULMONARY STATUSINST PREVENTION OF COMPLICATIONS IE AVOID OVER-EXERTION CHILLING CROWDS ETC
INST D ISEASE PROCESS amp MAINTENANCE
INSTRUCT COUGHING DEEP BREATHING EXERCISES INST PATIENT TO MAINTAIN ADEQUATE REST PATTERN
MANAGEMENT AND EVALUATION OF A PATIENT CARE PLAN TEACHING AND TRAINING DISEASE PROCESS SKIN CARE WOUND CAREDRESSING CHANGE DECUBITUS CARE MEDICATION REGIMEN DIETNUTRITIONHYDRATION COMPLICATIONS OF ENT FEEDING AS INDICATED
PAIN CONTROL MEASURES SYMPTOM CONTROL MEASURES SINGSSYMPTOMS OF INFECTION SAFETYPREVENTION OF INJURY EMERGENCY PLANS OXYGEN ADMINISTRATION
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GOALSREHABILITATION POTENTIAL CMS485 (POC)Included as reference only your Professional Staff must reviewupdatepersonalizeapprove the goals
DISCHARGE PLANNING DISCUSSED WITH PATIENT Yes No REHAB POTENTIAL ExcellentPoor Fair Good
SIGNATUREDATES
X DateStaff Completing the OASIS (signaturetitle)
OASIS INFORMATION
Data Entry Date amp Locked Date SubmittedQA Date Reviewed
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SN - GOALSMRMS _________________ WILL EXHIBIT VITAL SIGNS WITHIN ACCEPTABLE RANGE AND STABILIZED DISEASE PROCESSVERBALIZES KNOWLEDGE OF DISEASE MANAGEMENT MEDICATIONS SIDE EFFECTS PRECAUTIONS DIET FLUIDS TREATMENT PROGRAM SS NECESSITATING MEDICAL ATTENTION EMERGENCY CARE
STABILIZATION OF PSYCHOLOGICAL STATUS WITHIN DISEASE LIMITS TO REDUCE THE PATIENTS ANXIETY LEVELDEPRESIONANXIETY CONTROLED TROUGH MED REGIMEN INTERVENTIONS
ANEMIA CONTROLLED THROUGH MED REGIMEN IMPROVED HEMATOLOGIC STATUS
General
Psychiatric
A n e m i aHEALED WOUND WITHOUT INFECTION OR COMPLICATIONS DEMONSTRATE PROPER WOUND CARE
Wound Care
PTSO SHOULD UNDERSTAND THE NATURE SYMPTOMS STAGE AND PROGRESSION OF ALZHEIMERS DISEASEKNOW HOW TO RECOGNIZE PTS OWN STRESS AND WAYS TO PREVENT OR REDUCE IT PROMOTE SOCIAL INTERACTION AS TOLERATED BY THE PATIENT
Decubitus
DEMONSTRATE STRATEGIES TO BE USED DURING A COUGHING EPISODE HELP THE PATIENT IDENTIFY FACTORSTHAT MAY CAUSE ASTHMA ATTACKS OR CONTRIBUTE TO THEMAsthma
SAFELY ADMINISTERS INJECTION COMPREHEND RATIONALE FOR AND IS ABLE TO ROTATE INJECTION SITESCOMPREHEND SAFETY FACTORS IN SYRINGENEEDLE DISPOSALPATIENTCG ABLE TO MONITOR BLOOD SUGAR CORRECTLY WITHOUT ASSISTANCEABLE TO NOTIFY MD OF ALTEREDOUT OF RANGE RESULTS
InsulinGlucometer
DISCHARGE PT WHEN BLOOD SUGARS ARE WITHIN THE NORMAL FOR PATIENT RANGEKNOW THE ACCEPTABLE RANGE FOR BLOOD SUGAR LEVEL COMPLY WITH DIET RESTRICTIONS Diabetes
MellitusRETURN TO SELF-MANAGEMENT OF HEALED FRACTURED
FractureKNOW ABOUT SIGNS SYMPTOMS AND PRECIPITATING CAUSES OF CHF KNOW HOW TO TAKE THE PULSE AND KNOWTO CONSULT THE DOCTOR BEFORE CONTINUING MEDICATION IF THE PULSE RHYTHM CHANGES KNOW TOA V O I D S M O K I N G A N D S M O K Y E N V I R O N M E N T S A N D P E R S O N S W I T H I N F E C T I O N S E S P E C I A L L Y R E S P I R A T O R Y I N F E C T I O N S
CHF
UNDERSTAND THAT HYPERTENSION IS A CHRONIC DISEASE REQUIRING LIFE LONG TREATMENT EXHIBIT BLOODPRESSURE READINGS CONSISTENTLY WITHIN NORMAL OR SPECIFIED RANGE DEMONSTRATE ADHERENCE TO ALOW-SALT LOW-FAT DIET
Hypertension
HELP THE PATIENT ACHIEVE PAIN RELIEVE AND REDUCE ANGINA EPISODES UNDERSTAND THE CAUSE OFANGINA PECTORIS AND POSSIBLE PRECIPITATING FACTORS FOR AN ATTACK IDENTIFY PERSONAL STRESSORSTHAT MAY CONTRIBUTE TO THE PROBLEM AND BEGIN ELIMINATING OR MINIMIZING THEM KNOW WAYS TOREDUCE THE FREQUENCY OF ANGINA EPISODES
Angina
HEALED DECUBITUS WITHOUT INFECTION OR COMPLICATIONS DEMONSTRATE PROPER DECUBITUS CARE
Alzheimers
UNDERSTAND SS OF BRONCHITIS OR OTHER RESPIRATORY INFECTION AND DISEASE EXACERBATIONUNDERSTAND THE DANGERS OF SMOKING AIR AND CHEMICAL POLLUTANTS AND RESPIRATORY INFECTIONUNDERSTAND AND PRACTICE COUGHING AND DEEP-BREATHING EXERCISES
Respiratory
DAILY COMPLIANCE WCATHETER CARE DECREASE RISK OF URINARY INFECTIONCatheter
INCREASED PAIN RELIEF INCREASED STRENGTH AND ENDURANCE COMPREHEND AND DEMONSTRATE HOME EXERCISEOsteoarthritis
AIDE - GOALS
GAIT PATTERN ENDURANCE STRENGTH AND BALANCE WILL IMPROVE AND PATIENT WILL DEMONSTRATECORRECT BODY MECHANICS WIN 4-6 WKS PTCG WILL COMPREHEND AND DEMONSTRATE HOME EXERCISEPROGRAM WITHIN 4-6 WKS
FAIR-TO BE ABLE TO CARRY OUT MINIMAL ADLS WITH AVAILABLE HOME SUPPORTWILL NOT BE ABLE TO CARRY OUT ADLS WITHOUT MAXIMUM SUPPORT
RETURN TO INDEPENDENT AMBULATION BE SAFE IN SELF CAREPATIENT WILL BE ABLE TO FUNCTION WITH ASSISTANCE OF CAREGIVERWITHIN HESHE CURRENT LIMITATIONS AT HOME
PATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HISHER CURRENT LIMITATIONS AT HOME
PT - GOALS
GOOD RETURN TO PREVIOUS LEVEL OF ADLS INDEPENDENTLY
GAIT PATTERN ENDURANCE STRENGTH AND BALANCE WILL IMPROVE AND PT WILL DEMONSTRATECORRECT BODY MECHANICS WITHIN _____ WEEKS
PATIENT WILL EXPERIENCE A DECREASE IN PAIN
PTCG WILL COMPREHEND AND DEMONSTRATE HOME EXERCISEPROGRAM WITHIN _____ WEEKS
OT PATIENT WILL EXHIBIT IMPROVEMENT IN COPING IN ADLSIADLS MUSCLE USEMOTORCOORDINATIONNEURO RESPONSEUSE OF ORTHOTIC SPLINTING ANDOR EQUIPMENT
OT - GOALS
PATIENT WILL DEMONSTRATE FUNCTIONAL COMMUNICATIONS EXHIBIT MAXIMUM VERBAL AND SENTENCEFORMULATION AND COMPREHENSION WITHIN DISEASE LIMITS WITHIN _____ WEEKS
ST - GOALS
PATIENT WILL DEMONSTRATE APPROPRIATE USE OF FUNCTIONAL VERBALNON-VERBALCOMMUNICATIONS SYSTEMS WITHIN _____ WEEKS
PATIENT WILL DEMONSTRATE IMPROVED READINGWRITING USE OF GESTURESNUMBERS WITHIN _____ WEEKS
PATIENT WILL DEMONSTRATE IMPROVED SWALLOWINGCHEWINGORALMOTOR CONTROL WITHIN _____ WEEKS
PATIENT WILL HAVE ADEQUATE SUPPORT TO REMAIN IN HOME WITH ASSISTANCE OF COMMUNITYRESOURCES FOR FINANCIAL TRANSPORTATION AND PERSONAL CARE ASSISTANCE WITHIN _____ WEEKS
MSW - GOALSPSYCHOSOCIAL EVALUATION WILL BE PERFORMED PTCG WILL BE COUNSELED REGARDING MANAGEMENTamp ADJUSTMENT TO ILLNESS LONG TERM PLANNING AND DECISION MAKING APPROPRIATE COMMUNITYRESOURCE REFERRALS WILL BE MADE
WILL DISCHARGE THE PATIENT WITHIN 60 DAYS WHEN PATIENT ANDORCAREGIVER ISARE ABLE TO DEMONSTRATE KNOWLEDGE OF DISEASE MANAGEMENT SS COMPLICATIONSPATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HISHER CURRENT LIMITATION AT HOME
ABLE TO REMAIN IN HOMERESIDENCEALF WITH ASSISTANCE OF PRIMARY CAEGIVERSUPPORT AT HOMEABLE TO UNDERSTAND MEDICATION REGIMEN AND CARE RELATED TO HISHER DISEASEWILL BE DISCHARGE WHEN MAXIMUM FUNCTIONAL POTENTIAL REACHED
Patient Name Med Record
wwwpnsystemcom 3058185940 The Outcome and Assessment Information Set (OASIS) is the intellectual property of the Center for Health Services and Policy Research Denver Colorado It is used with permission Expiration date 7312012
XPatient Signature if required optional if itinerary is used
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- OASIS_C_SOC
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- PT ID PERFORMED VIA NAME DOB FACE RECOGNITION AND ADDRESS BEFORE SERVICE PROVIDED Off
- TIME IN
- TIME OUT
- Agency Name SALUD HOME CARE INC
- Phone 305-555-5555
- Employees NameTitle Completing the OASIS
- who has signed the plan of care
- Physician name
- Address 1
- Address 2
- Phone Number
- Address 1_2
- Address 2_2
- Patient Phone
- Reason
- Name
- Other Physician if any
- Phone_2
- Address 1_3
- Address 2_3
- Phone Number_2
- REFERRAL SOURCE if not from Primary Physician
- undefined_6
- Phone_3
- Fax
- Evacuation Form needed Emergency Reg 1
- Evacuation Form needed Emergency Reg 2
- EMERGENCY CONTACT
- Address
- Comments 1
- Comments 2
- Phone_4
- Relationship
- OTHER
- Comment 1
- Comment 2
- 11 Other specify
- a
- b
- 7 Other specify
- c
- d
- e
- f
- a_2
- b_2
- d_2
- e_2
- f_2
- a_3
- b_3
- d_3
- Comment if needed 1
- Comment if needed 2
- a_4
- a_5
- a_6
- Date 23
- undefined_7
- undefined_8
- b_4
- b_5
- b_6
- Date_2
- undefined_9
- undefined_10
- Date_3
- undefined_11
- undefined_12
- d_4
- d_5
- d_6
- Date_4
- undefined_13
- undefined_14
- Date_5
- undefined_15
- undefined_16
- Date_6
- undefined_17
- undefined_18
- 12 1
- 12 2
- Date_7
- undefined_19
- undefined_20
- Date_8
- undefined_21
- undefined_22
- MAIN REASON FOR HOME HEALTH CARE 1
- MAIN REASON FOR HOME HEALTH CARE 2
- Fractures site
- Surgeries site
- Cancer site
- Open Wound site
- Decubitus site
- Other specify
- Other
- Pending or Needed
- Yes Number of times
- Reason s Dates
- MobilityAmbulatory devices used
- Other specify_2
- undefined_23
- Comments if needed 1
- Comments if needed 2
- Comments if needed 3
- Comments if needed 4
- undefined_24
- Name_2
- Phone number if different from patient
- Relationshiphealth statusability to help 2
- Any paid help explain
- Specify 1
- Specify 2
- Specify 3
- Any ears surgeryprocedure
- Date_9
- Otherspecify 1
- Otherspecify 2
- Other agencies involved in care 1
- Other agencies involved in care 2
- 1
- 2
- Other_2
- Infections
- Cataract surgery Site
- Date_10
- Other eyes surgery Site
- Date_11
- explain 1
- explain 2
- Any nose surgery
- Date_12
- Other specify_3
- 1_2
- 2_2
- MassesTumors site
- Lesions explain
- Any surgeryprocedure
- Other specify 1
- Other specify 2
- Other specify 3
- Date_13
- Other specify_4
- No Problem
- Medication
- Other_3
- Pain control treatmentmeds Side effect mark
- Other_4
- Is there a regular pattern to the pain explain
- Other_5
- Comment
- What was the outcome
- Type II OnsetExacerbation date
- DietOral control specify
- INSULIN dosage frequency scale explain
- 1_3
- 2_3
- Since
- Other_6
- A1c
- BS
- mgdL DateTime
- Blood sugar ranges
- site 1Location site
- site 2Location site
- site 3Location site
- Frequency
- Other_7
- site 1New Onset Exacerbation
- site 2New Onset Exacerbation
- site 3New Onset Exacerbation
- Able to use Glucometer
- site 1Present level 010
- site 2Present level 010
- site 3Present level 010
- Diabetes Management Problems explain 1
- Diabetes Management Problems explain 2
- Other Endocrine problems
- site 1Occasional y Cont Intermittent Frequency Frequently
- site 2Occasional y Cont Intermittent Frequency Frequently
- site 3Occasional y Cont Intermittent Frequency Frequently
- site 1Pain type ach ng burn ng rad ating neura gia etc
- site 2Pain type ach ng burn ng rad ating neura gia etc
- site 3Pain type ach ng burn ng rad ating neura gia etc
- Anemia specify type if known
- site 1Feeling of pain internal external acute chronic
- site 2Feeling of pain internal external acute chronic
- site 3Feeling of pain internal external acute chronic
- site 1Pain is worse morning
- site 2Pain is worse morning
- site 3Pain is worse morning
- Immunodeficiency problems explain
- Other 1
- Other 2
- Other_8
- explain 1_2
- explain 2_2
- explain 3
- explain 4
- Other specify 1_2
- Other specify 2_2
- undefined_25
- undefined_26
- undefined_27
- undefined_28
- undefined_29
- undefined_30
- undefined_31
- undefined_32
- undefined_33
- undefined_34
- undefined_35
- undefined_36
- M1310 Pressure Ulcer Length Longest length headtotoe
- undefined_37
- cm
- greatest width perpendicular to the length
- M1314 Pressure Ulcer Depth Depth of the same pressure ulcer from
- cm_2
- visible surface to the deepest area
- undefined_38
- cm_3
- 1_4
- 2_4
- 3_2
- Other_9
- 4_2
- Caregiver name
- Other_10
- cant integument findings
- Observation
- Observation_2
- Caregiver name_2
- Other_11
- Wound cleaned with specify
- Wound irrigated with specify
- 1 Size
- cm width
- Wound packed with specify
- Location
- Other_12
- Wound dressingcover applied specify
- 2 Size
- cm width_2
- Comments 1_2
- Comments 2_2
- Location_2
- Other_13
- Sizecm LengthxWidthxDepth
- Sizecm LengthxWidthxDepth_2
- Diagram 4Sizecm LengthxWidthxDepth
- Tunneling Undermining cm
- Tunneling Undermining cm_2
- Diagram 4Tunneling Undermining cm
- Stage IIIIIIIV pressure uIcers only
- Diagram 4Stage IIIIIIIV pressure uIcers only
- Odor Fool normal etc
- Diagram 4Odor Fool normal etc
- Edema pedal sacral p tting etc
- Diagram 4Edema pedal sacral p tting etc
- Appearance of the Wound Bed
- Diagram 4Appearance of the Wound Bed
- Treatment Ordered
- Diagram 4Treatment Ordered
- Other_14
- Other_15
- Other_16
- Other_17
- Yes 1
- Yes 2
- Yes 3
- Height
- Weight
- Radiating to
- GainLoss
- lb X
- Frequencyduration
- Sittinglying R
- L
- Standing R
- L_2
- Medication_2
- Temperature
- Other_18
- Apical
- Brachial
- Radial
- Carotid
- Dependent
- Pitting 1234
- Respirations
- Site
- Cramps site
- Disease Management Problems explain
- Right Upper
- Right
- Right Lower
- 1_5
- 2_6
- 3_3
- Left
- Left Upper
- Left Lower
- Pacemaker Date
- Last date checked
- SOB on minimal effortwalk
- Type
- fy
- Other Prob 1
- Other Prob 2
- O2
- Trach sizetype
- CaregiverfamilyOther
- Yes explain 1
- Yes explain 2
- Other_19
- Comments 1_3
- Comments 2_3
- Increase fluids
- Restrict fluids
- Frequency_2
- Amount
- Yes describe 1
- Yes describe 2
- Frequency_3
- Other 1_2
- Other 2_2
- Nocturia x
- Bowel Off
- undefined_52
- Diapersother
- Other_20
- No
- 2TOTAL
- Urinary Catheter Type
- Last changed on
- Foley inserted date
- with
- Inflated balloon with
- Irrigation solution Type specify
- Amount_2
- mL Frequency
- Returns
- No_2
- 1_6
- 2_7
- Describe at risk intervention and plan 1
- Describe at risk intervention and plan 2
- Describe at risk intervention and plan 3
- DischargeDrainage describe
- Lesions
- Blisters
- Masses
- Cysts
- Wart
- Other specify_5
- Surgical alteration
- Prostate problem BPH TURP Date
- undefined_53
- undefined_54
- Selftesticular exam Frequency
- Hysterectomy Date
- undefined_55
- undefined_56
- Date last PAP
- undefined_57
- undefined_58
- Results
- Breast selfexam frequency
- Mastectomy R L Date
- undefined_59
- undefined_60
- Other specify_6
- Last BM
- Diarrhea Frequency
- Bowel regimeprogram
- Incontinence Off
- Urinary Off
- Diapersother_2
- Other_21
- te describe skin around stoma
- Ileostomycolostomy s 2
- Ileostomycolostomy s 3
- Ileostomycolostomy s 4
- Ileostomycolostomy s 5
- Headache Location
- Frequency_4
- Other_22
- Migraine Frequency
- Site_2
- Weakness UE LE Location
- Other specify_7
- Site_3
- IV
- Pump typespecify
- Hand grips Equal Unequal specify
- Feedings Type amtrate
- Strong Weak specify
- Psychotropic drug use specify
- Flush Protocol amtspecify
- DoseFrequency
- Other_23
- Other specify 1_3
- Other specify 2_3
- DressingSite care specify 1
- DressingSite care specify 2
- Interventions instructionsComments 1
- Interventions instructionsComments 2
- Following Un
- versalStandard precautions
- NA
- No Problem_2
- Pain Frequency
- Abdominal girth
- Bowel sounds active absent hypo hyperactive x
- 3 Forgetful Off
- 4 Depressed Off
- 6 Lethargic Off
- 5 Disoriented Off
- 7 Agitated Off
- 2 Comatose
- 8 Other Off
- Forgetful at times Off
- Irritable Off
- Anxious Off
- Alert Off
- Describe 1
- Describe 2
- undefined_61
- Needs interpreter
- Comments 1_4
- Comments 2_4
- Higher Educational Level
- Fracture location
- Swollen painful joints specify
- Explain
- Contractures Joint
- Spiritual resource
- Location_3
- Phone No
- Atrophy
- Other_27
- Explain 1
- Explain 2
- Decreased ROM
- Paresthesia
- Weakness
- Other_28
- Inappropriate followthrough in past
- Amputation BKAKUE RL specify 1
- Amputation BKAKUE RL specify 3
- Amputation BKAKUE RL specify 4
- Treatment
- Treatment_2
- Other specify 1_4
- Other specify 2_4
- History of Falls past 3 months 12 falls M1032
- V s on Status Poor w or w o glasses M1200
- Vision Status Poor Legally blind M1200
- Gait and Balance Balance problem while standing
- Gait and Ba ance Balance problem while walking
- Gait and Balance Decreased muscular coordination
- Pred spos ng D seases 12 present
- Predisposing D seases 3 or more present
- Equipment Issues Oxygen tubing
- 1Row1
- PlanComments 1
- PlanComments 2
- Comment_2
- undefined_62
- b Ambulation
- c Transfer
- DOther specify
- 7Independent in home 1
- 7Independent in home 2
- Other 1_3
- Other 2_3
- Typebrand
- Size
- Gauge
- Length
- Insertion site
- Insertion date
- Flush solution
- Frequency_5
- Injection cap change frequency
- Dressing change frequency
- Other_29
- Siteskin condition
- External catheter length
- OtherComment
- fluid overload Other
- Circumference of arm
- Huber gaugelength
- Yes date
- Last flushed date
- Siteskin condition_2
- Infusion solution typevolumerate
- Dressing
- OtherComment 1
- OtherComment 2
- Drug Name
- Dose
- Route
- Frequency_6
- Duration of therapy
- Drug Name_2
- Dose_2
- Route_2
- Frequency_7
- Duration of therapy_2
- CommentPlan 1
- CommentPlan 2
- Pump type specify
- Other_30
- Lab draws
- Infusion care provided during visit 1
- Infusion care provided during visit 2
- Infusion care provided during visit 3
- Antibiotic therapy
- 1_7
- 2_8
- Other_31
- Removing line date if know
- BraceOrthotics specify 1
- BraceOrthotics specify 2
- BraceOrthotics specify 3
- Needs specify 1
- Needs specify 2
- Oxygen HME Co
- Prosthesis RUE RLE LUELLEOther
- HME Rep
- Grab bars BathroomOther
- Hospital bed Semielec Crank Spec
- Other_32
- NA_2
- Phone_5
- n care
- PlanComments
- N
- Other_33
- undefined_63
- Physical Therapy Total visits
- Speech Therapy Total visits
- visits
- Other Therapy Total visits
- Patient is not assessed to be at risk for falls
- No pain identified
- Patient has no pressure ulcers with need for moist wound healing
- O
- Noncompliance with drug orders
- Expected Outcome
- Patient unable to perform own Wound Care due
- Pat
- to
- Abd Pads Off
- Underpads size
- undefined_68
- Special mattress overlay
- Angiocatheter size
- Ostomy pouch brand size
- Pressure relieving device
- Ostomy wafer brand size
- undefined_69
- SYRINGES
- Batteries size
- Skin protectant
- Glucometer
- Hydrocolloids
- undefined_70
- FOLEYCATH SUPPLIES
- Syringes size
- size
- Oxygen concentrator
- Feeding tube
- Ointment
- Acetic acid
- Other 1_4
- Other 2_4
- Other 3
- Tens unit
- KLING 4
- Other 1_5
- Other 2_5
- Other 3_2
- PatientCG educationteaching this visit for
- MEDICATION Off
- DISEASE PROCESS COMPLICATIONS Off
- undefined_71
- SS OF Off
- ILEAL CONDUITOSTOMY Off
- DIET FLUIDS Off
- undefined_72
- undefined_73
- SKINFOOT CARE Off
- INFECTION CONTROL Off
- OTHER INSTRUCTIONS GIVEN
- Caregiver present during the visit
- NEEDS FURTHER TEACHING Off
- No_3
- Skilled Observation Assessment
- ent Educat
- Wound Care Dress
- Diabetic Observation Care
- Correct handwashing technique followed SG 1
- Correct handwashing technique followed SG 2
- Correct handwashing technique followed SG 3
- Correct handwashing technique followed SG 4
- 21 Included as reference only your Professional Staff must reviewupdatepersonalizedapprove the orders
- SN ORDERS FREQUENCYDURATION
- S COMPLICATIONS
- TH GLUCOMETER OR
- ON
- TEACH GLUCOMETER OR
- NSERTION
- TH
- INST DRESSING CHANGES
- MONITOR STATUS OF WOUND OR DECUBITUS place
- ADMINISTER PRESCRIBED INJECTABLE
- USING
- TH_2
- TH_3
- AND APPLY
- CLEANSE WOUND WITH
- NSE WITH
- AND APPLY_2
- OTHER_2
- DE ORDERS FREQUENCYDURATION
- PT ORDERS FREQUENCYDURATION
- OT ORDERS FREQUENCYDURATION
- ST ORDERS FREQUENCYDURATION
- MSW ORDERS FREQUENCYDURATION
- Included as reference only your Professional Staff must reviewupdatepersonalizeapprove the goals 22
- MRMS
- PROGRAM WITHIN
- CORRECT BODY MECHANICS WITHIN
- COMMUNICATIONS SYSTEMS WITHIN
- undefined_75
- undefined_76
- Date_14
- QA Date Reviewed
- undefined_77
- undefined_78
- Data Entry Date Locked
- undefined_79
- undefined_80
- Date Submitted
- undefined_81
- undefined_82
- SOCD
- SOCM
- SOCY
- SOCM1
- SOCD1
- SOCY1
- Check Box2 Off
- Check Box3 Off
- Check Box4 Off
- TOM
- TOD
- TOY
- FDM
- FDD
- FDY
- Prov 1071523
- BrID
- Check Box9 Yes
- BrIDno
- Check Box11 Off
- DLCM
- DLCD
- DLCY
- LVM
- LVD
- LVY
- DNR1 Off
- Check Box19 Off
- STFL
- PZC
- MCN
- NOMC Off
- SSN1
- SSN2
- SSN3
- SSUK Off
- MAN
- MAUK Off
- DOBM
- DOBD
- DOBY
- SEX Off
- MR
- First
- MI
- Last
- Suffix
- RACE2 Off
- RACE3 Off
- RACE4 Off
- RACE5 Off
- RACE1 Off
- RACE6 Off
- PS3 Off
- PS0 Off
- PS1 Off
- PS4 Off
- PS5 Off
- PS6 Off
- PS7 Off
- PS8 Off
- PS9 Off
- PS10 Off
- PS11 Off
- PS2 Off
- PSUK Off
- Ecode
- COMP Off
- DACM
- DACD
- DACY
- REA Off
- DM
- DD
- DY
- RDM
- RDD
- RDY
- REFDM
- REFDD
- REFDY
- EPT Off
- 14D2 Off
- 14D3 Off
- 14D4 Off
- 14D5 Off
- 14D6 Off
- 14D7 Off
- 14D8 Off
- Check Box39 Off
- icd9c
- icd9a
- icd9b
- icd9d
- icd9e
- icd9f
- Check Box5 Off
- Check Box7 Off
- icd9b2
- icd9c2
- icd9d2
- C_2
- icd9e2
- icd9f2
- icd9a2
- icd9b3
- icd9c3
- C_3
- icd9a3
- icd9d3
- 1005d
- 1005m
- 1005y
- 1018-2 Off
- 1018-1 Off
- 1018-4 Off
- 1018-5 Off
- 1018-6 Off
- 1018-7 Off
- 1018-NA Off
- 1018-UK Off
- 1018-3 Off
- 1012-na Off
- 1012-uk Off
- Radio Button11 Off
- v1020b
- C_5
- e_5
- f_5
- C_6
- e_6
- f_6
- c_4
- e_4
- f_4
- v1020c
- v1020d
- v1020e
- v1020f
- v1020a
- e1020b
- e1020c
- e1020d
- e1020e
- e1020f
- e1020a
- ev1020b
- ev1020c
- ev1020d
- ev1020e
- ev1020f
- ev1020a
- sp12-1
- sp12-2
- Radio Button12 Off
- Radio Button13 Off
- rad0 Off
- rae0 Off
- rdf0 Off
- phhp Off
- phrp1 Off
- phot1 Off
- phoa1 Off
- phfc1 Off
- phca1 Off
- phin1 Off
- phga1 Off
- phif1 Off
- phsg1 Off
- phwd1 Off
- phdc1 Off
- phgn1 Off
- rddmi Off
- imin Off
- inh1n1 Off
- fwpn Off
- fwtn Off
- fwot Off
- phdm1 Off
- PHNY Off
- phcd1 Off
- 10304 Off
- 10301 Off
- 10302 Off
- 10303 Off
- 10327 Off
- M1034 Off
- HBR1 Off
- HBR2 Off
- HBR3 Off
- HBR4 Off
- HBR5 Off
- HBR6 Off
- HBR7 Off
- HBR8 Off
- HBR9 Off
- HBR11 Off
- HBR12 Off
- HBR10 Off
- HBR13 Off
- SOBFT
- 10321 Off
- 10322 Off
- 10333 Off
- 10324 Off
- 10325 Off
- 10336 Off
- M11001 Off
- M1100b Off
- M1100c Off
- Relationshiphealth statusability to help 1
- 10361 Off
- 10362 Off
- 10363 Off
- 10364 Off
- 10365 Off
- 10366 Off
- 1210d Off
- 1210an Off
- 1210hea Off
- 1210OTH Off
- 1210TIN Off
- 1210NP Off
- 12102 Off
- 12101 Off
- 1210uk Off
- 1210h Off
- 1210v Off
- 1200CAT Off
- 1200OTH Off
- 1200JA Off
- 1200CATRL Off
- 1200OTHER Off
- 1200PT Off
- 1200GLAU Off
- 1200NOP Off
- NOSECON Off
- NOSEEP Off
- NOSELS Off
- NOSESINP Off
- NOSEASG Off
- NOSEOTHSP Off
- NOSENP Off
- THROATDY Off
- TROATL Off
- THROATOTH Off
- 1200BV Off
- 1200LB Off
- THROATHO Off
- THOATSO Off
- THROATNP Off
- 1200GL Off
- 1200CO Off
- 1200PR Off
- 1200IN Off
- M1200 Off
- M1220 Off
- M1230 Off
- MOUTHMas Off
- MOUTHGI Off
- MOUTHULC Off
- MOUTHTOO Off
- MOUTHANY Off
- MOUTHOTH Off
- MOUTHNP Off
- M1240 Off
- M1242 Off
- MOUTHDE Off
- MOUTHUP Off
- MOUTHLO Off
- MOUTHPAR Off
- COPYN Off
- MKMEDP Off
- CPCYN Off
- DPRYN Off
- ICPYN Off
- TURGGP Off
- BESTPAINSC2
- WORSES2
- BESTPAINSC
- WORSESC
- BESTPAINSC3
- WORSESC3
- FACESOBS Off
- SCALE010 Off
- WPSL Off
- WPMA Off
- WPMV Off
- WPAMB Off
- WPIMM Off
- WPTR Off
- WPOTH Off
- WPNP Off
- NVIM Off
- WRP4 Off
- WRP5 Off
- WRP6 Off
- WRP7 Off
- WRP8 Off
- WRP9 Off
- WRPOTH Off
- TKMEDNV Off
- TKMEDLDD Off
- TKMEDD Off
- TKMED23 Off
- TKMEDLT3 Off
- PCTSL Off
- PTXSEN Off
- PTXSEV Off
- PTXSECF Off
- PRDOCC Off
- PTXSEOTH Off
- PRDCONT Off
- WRP1 Off
- WRP2 Off
- WRP3 Off
- PRDINT Off
- PRDFRQ Off
- PHYNOTPT Off
- PHYNOTSTF Off
- NVIG Off
- NVIC Off
- NVIAF Off
- DMIJUV Off
- DMTPII Off
- INSDGFQ Off
- DMODIET Off
- ADMOTH Off
- symphyg Off
- sympfat Off
- symhypog Off
- endopcgr Off
- endopostpra Off
- endorand Off
- endolab Off
- bsrange Off
- bsranptcg Off
- endomonsf Off
- endomoncg Off
- endomonsn Off
- endomonoth Off
- dmNapb Off
- othendopb Off
- enlthyr Off
- intoheatcol Off
- endonp Off
- HEMAANE Off
- HEMABLEED Off
- HEMAHEMO Off
- HEMAINMO Off
- HEMAOTH Off
- HEMANP Off
- SKINITCH Off
- SKINRASH Off
- SKINDRY Off
- SKINSCL Off
- SKINRED Off
- SKINBRU Off
- SKINECCH Off
- SKINPALL Off
- SKINJAU Off
- ADMSELF Off
- ADMSCGF Off
- ADMNURS Off
- SKINNP Off
- m1300 Off
- M1302 Off
- M1306 Off
- M1320 Off
- M1322 Off
- M1324 Off
- M1330 Off
- M1332 Off
- M1334 Off
- M1340 Off
- M1342 Off
- M1350 Off
- WCPYN Off
- IPDMYN Off
- APHYN Off
- SDRBY Off
- SDRSN Off
- SDRCG Off
- SDRPT Off
- SDROTH Off
- TECST Off
- TECCL Off
- WDCLW Off
- WDIRRW Off
- WDPKW Off
- WDDREW Off
- DBFEXD Off
- DBFEX2D Off
- DBFEXEOD Off
- DFEX2WK Off
- DBNFEXWK Off
- DFEXOTH Off
- PDPPRL Off
- PDPARL Off
- LSWRL Off
- endobm Off
- endotv Off
- fbs Off
- LSCDRL Off
- ASCCFR Off
- ASCCFL Off
- Right for
- ASCCFLF
- TRINR Off
- BURRL Off
- LEGHP Off
- LEGHAB Off
- DBFEXRN Off
- DFEXCG Off
- DBFEXPT Off
- DBFEXOT Off
- EXSER Off
- EXSERG Off
- EXSANG Off
- EXSER2 Off
- EXSERG2 Off
- EXSANG2 Off
- SHOV Off
- SHAPRD Off
- SHAPOTH Off
- SHOV2 Off
- SHAPRD2 Off
- SHAPOTH2 Off
- cm length
- cm length2
- DBFTEXRNPT Off
- EXDYN Off
- EXDYN2 Off
- APHYN2 Off
- APHYN3 Off
- Loc3w
- Loc2w
- Loc1w
- Loc4w
- Typew1
- Typew2
- Typew3
- Typw4
- sizw3
- tunnw3
- surrw1
- stomaw1
- surrw1a
- stomaw1a
- surrw3
- surrw3a
- stomaw3
- stomaw3a
- surrw2
- surrw2a
- stomaw2
- stomaw2a
- surrw4
- surrw4a
- stomaw4
- stomaw4a
- statgew2
- statgew3
- Odorw2
- Odorw3
- Edemaw2
- Edemaw3
- appw2
- appw3
- Treatment Ordered_2
- Treatment Ordered_3
- Group10 Off
- draick2 Off
- driack3 Off
- draick4 Off
- colw11 Off
- colw12 Off
- colw31 Off
- colw32 Off
- colw33 Off
- colw34 Off
- colw21 Off
- colw22 Off
- colw23 Off
- colw24 Off
- colw43 Off
- colw44 Off
- ital1u1 Off
- ital1u2 Off
- fsrrepo Off
- frsact Off
- rwgchpt Off
- rwgchcgf Off
- rwgchnur Off
- pulreg1 Off
- pulirreg1 Off
- fsrrespreg Off
- colw41 Off
- colw42 Off
- bpsitly Off
- bpstand Off
- fsrwgrep Off
- fsrwgact Off
- tempaxil Off
- temptymp Off
- pulseappical Off
- pulseradial Off
- pulsebrach Off
- pulsecarot Off
- pulserest Off
- pulsecheyn Off
- pulseactiv Off
- respirirreg Off
- respideath Off
- respaccess Off
- respiapnea Off
- bsckrack Off
- temporal Off
- temprect Off
- chestprad Off
- colw13 Off
- colw14 Off
- consth2 Off
- consthic2 Off
- consth3 Off
- consthic3 Off
- consth4 Off
- consthic4 Off
- chestpyes Off
- chestpainno Off
- consth1 Off
- consthic1 Off
- cpsubstern Off
- cpviselike Off
- dm5lin
- assocwithsoboe Off
- associawactv Off
- associwsweat Off
- cphowreloth Off
- cphowrelrest Off
- cphowrelmeds Off
- cppalarr Off
- cppalpfast Off
- cppalpslow Off
- cppalpfatig Off
- cpedema Off
- cpedemapedal Off
- cpangina Off
- cppostural Off
- cplocalized Off
- cpedempedrig Off
- cpedemapedallef Off
- cpedemasacral Off
- cpedemadepend Off
- cpedemapitt Off
- cpedemanonpitt Off
- cstcramp Off
- cardstclaud Off
- cardstcapref Off
- cstcaprefless Off
- castcaprefgreat Off
- csthsreg Off
- csthsirreg Off
- csthsmurmur Off
- cstpacemak Off
- cpstabreassouclear Off
- breassodwheez Off
- bresddimm Off
- chestpaidull Off
- cpache Off
- cpsharp Off
- brsdabset Off
- brsdsobsoboe Off
- brsdsobonmineff Off
- 14001 Off
- 14003 Off
- 14004 Off
- 1400tva Off
- 14002 Off
- 1400car Off
- 14101 Off
- 14102 Off
- 14103 Off
- 14104 Off
- uroops Off
- uropat Off
- urocare Off
- 14000 Off
- urosn Off
- Radio Button2 Off
- 16100 Off
- 16101 Off
- 1400pat Off
- 16concar Off
- 162gm Off
- 16nas Off
- 16npo Off
- 16102 Off
- 161800cal Off
- 16lowfat Off
- 16lowcho Off
- 16incflu Off
- 16restflu Off
- 16exc Off
- 16good Off
- 16fair Off
- 16poor Off
- 16anore Off
- 16nau Off
- 16vom Off
- 16heabur Off
- O2satur
- O2firesaf Off
- O2sn Off
- O2carefamother Off
- O2cough Off
- O2no Off
- O2yes Off
- O2nonprod Off
- O2noc Off
- O2yesc Off
- O2dys Off
- O2rest Off
- O2dADL Off
- O2sliplo Off
- O2nop Off
- O2yesp Off
- 16other Off
- genibur Off
- genihes Off
- genihema Off
- geniolig Off
- geniurg Off
- geninoc Off
- geniincon Off
- geniuri Off
- genidiap Off
- 16lowna Off
- genicyell Off
- genicamber Off
- genicbr0 Off
- genicbt Off
- genicother Off
- genicla Off
- geniclo Off
- genised Off
- geniodno Off
- genifol Off
- geniwitdif Off
- genisup Off
- geniyes Off
- genino Off
- 1620 Off
- 1615 Off
- 1630 Off
- 1630cosn Off
- 1630lBM Off
- 1630diar Off
- 1630rect Off
- 1630hemo Off
- 1630incon Off
- 1630diap Off
- 1630lax Off
- 1630w Off
- 1630d Off
- 1630m Off
- 1630lleost Off
- 1630pat Off
- 1630car Off
- 1630sn Off
- 1630ot Off
- 1630np Off
- 1630follow Off
- genblis Off
- genmass Off
- gencys Off
- genwart Off
- geninf Off
- gensurg Off
- genprost Off
- gensef Off
- genmeno Off
- genhyst Off
- gendisc Off
- geniodyes Off
- gennp Off
- 1630flat Off
- 17001 Off
- 17002 Off
- 17004 Off
- 1700head Off
- 1700perr Off
- 1700up Off
- 1700apha Off
- 1700rec Off
- 1700exp Off
- 1700mot Off
- 1700gro Off
- 1700dom Off
- 1700weak Off
- 1700trem Off
- 1700fine Off
- 1700gross Off
- 1700paral Off
- 1700stu Off
- 1700halluc Off
- 1700psy Off
- 1700oth Off
- 1700np Off
- EFAD TPN Off
- 17003 Off
- EFAD jej Off
- EFAD iv Off
- EFAD pum Off
- EFDA bol Off
- EFDA con Off
- EFA pat Off
- EFDA sn Off
- EFDA car Off
- EFDAoth Off
- EFDAfu Off
- EFDA na Off
- EFDA np Off
- abd pa Off
- ABD dis Off
- ABD hard Off
- ABD soft Off
- ABD asc Off
- ABD ab Off
- ABD oth Off
- ABD bow Off
- ABD other Off
- ABD ten Off
- EFAD Nas Off
- efad gas Off
- EFAD ot Off
- 17101 Off
- 17102 Off
- 17103 Off
- 17104 Off
- 17105 Off
- 17100 Off
- 1720 Off
- gen dis Off
- genbre Off
- genmast Off
- genoth Off
- 1700fin Off
- 1700mig Off
- genles Off
- 1630 other Off
- 1730 Off
- 1745 Off
- 1750 Off
- 17450 Off
- 1730a Off
- 1730b Off
- 17000 Off
- 17401 Off
- 17402 Off
- 17404 Off
- 17405 Off
- 17406 Off
- 17407 Off
- 1 Oriented Off
- msnp Off
- pslb Off
- psni Off
- psd Off
- psnas Off
- lbm Off
- lbps Off
- lbph Off
- lbf Off
- lbs Off
- urw Off
- sceri Off
- 17403 Off
- ps Off
- ABD pn Off
- pslm Off
- psdp Off
- pspl Off
- psrf Off
- psnh Off
- psue Off
- psir Off
- pse Off
- psep Off
- psea Off
- psvep Off
- psin Off
- psph Off
- psab Off
- psfin Off
- msor Off
- msfr Off
- msre Off
- msp Off
- mssw Off
- mscon Off
- msat Off
- msad Off
- mscan Off
- msuns Off
- mstp Off
- mswal Off
- msdec Off
- par Off
- msot Off
- mssh Off
- mswe Off
- mswea Off
- mskp Off
- msother Off
- mshe Off
- mspa Off
- msqua Off
- msoth Off
- msnop Off
- psina Off
- pssi Off
- psnap Off
- psinap Off
- psan Off
- psfat Off
- pswit Off
- psdif Off
- psdis Off
- psdep Off
- psanx Off
- psnp Off
- psade Off
- psdisc Off
- mscom Off
- msamp Off
- FL2 Off
- FL3 Off
- FL7 Off
- FL8 Off
- FL9 Off
- FLA-d Off
- FLb Off
- FLg Off
- FLart Off
- FLdiz Off
- FLhead Off
- FLins Off
- FLanx Off
- FLsob Off
- FLpoor Off
- FLprod Off
- FLheart Off
- FLp Off
- FLu Off
- FLv Off
- FLed Off
- FLc Off
- FLf Off
- FL1l Off
- FL1b Off
- FL1d Off
- FL1p Off
- FL1li Off
- FL1lr Off
- FL1lc Off
- FL1f Off
- FL1n Off
- FL4 Off
- FL6 Off
- FL5 Off
- adl o Off
- adl 1 Off
- adl 2 Off
- adl 3 Off
- 1810 0 Off
- 1810 1 Off
- 18102 Off
- 18103 Off
- 19100 Off
- 18200 Off
- 18201 Off
- 18202 Off
- 18203 Off
- FL1 Off
- 1910sg Off
- 1910sgp Off
- 1910sgd Off
- 1111910sgp Off
- 1910sgo Off
- 18302 Off
- 18301 Off
- 18300 Off
- 18304 Off
- 18305 Off
- 18306 Off
- 18400 Off
- 18401 Off
- 18402 Off
- 18403 Off
- 18404 Off
- 1910sgpat Off
- 18901 Off
- 18902 Off
- 18903 Off
- 18904 Off
- 18905 Off
- 1890na Off
- adlr Off
- adlna Off
- adlsn Off
- adlm Off
- adlp Off
- adlot Off
- adlst Off
- 18303 Off
- adlcom Off
- 1845 Off
- 1880 Off
- adl Off
- 1850 Off
- 1860 Off
- 1870 Off
- 1900a Off
- 1900b Off
- 1900d Off
- 1900c Off
- 18900 Off
- 19101 Off
- 19102 Off
- 19103 Off
- 19104 Off
- 19105 Off
- 19106 Off
- 19107 Off
- 19108 Off
- 19109 Off
- 1910aw Off
- 1910bw Off
- 1910cnr Off
- 1910do Off
- alleasp Off
- alleggs Off
- alleib Off
- allesulf Off
- allead Off
- alledm Off
- allelod Off
- allepol Off
- alledust Off
- alleother Off
- 20000 Off
- 2000na Off
- 14D1 Off
- 20001 Off
- 20002 Off
- 2010 Off
- 2002 Off
- 2040a Off
- 2040b Off
- 2020 Off
- 2030 Off
- infpat Off
- picccir Off
- ivadacc Off
- int Off
- fo Off
- fa Off
- ule Off
- infiv Off
- perip Off
- mc Off
- gros Off
- tun Off
- nt Off
- ld Off
- lt Off
- cl Off
- pat Off
- rn Off
- cg Off
- ivocc Off
- ivflu Off
- res Off
- red Off
- allerno Off
- iv-i Off
- adp Off
- adc Off
- adrn Off
- adoth Off
- pia Off
- athe Off
- eiv Off
- biood Off
- mva Off
- pn Off
- infna Off
- infcare Off
- rldna Off
- 2100a Off
- 2100b Off
- 2100c Off
- 2100d Off
- 2100e Off
- 2100f Off
- 2100g Off
- 2110 Off
- asheb Off
- ashmet Off
- asehmop Off
- asprost Off
- asebed Off
- aseshow Off
- asescoot Off
- asehoist Off
- asegrab Off
- asehosp Off
- aselif Off
- asewhee Off
- aseoth Off
- aseneed Off
- aseoxy Off
- asefire Off
- aseph Off
- aseorg Off
- asena Off
- smlasa Off
- pump Off
- smcou Off
- smght Off
- smpup Off
- smrp Off
- smwd Off
- smal Off
- smpco Off
- smpfi Off
- smsa Off
- smpic Off
- smsp Off
- smtsc Off
- smsd Off
- smgip Off
- smgup Off
- smst Off
- smcc Off
- smpes Off
- smep Off
- smms Off
- smcp Off
- smcpat Off
- smcht Off
- smcfsh Off
- smpsbp Off
- smoth Off
- oxgava Off
- oxknosw Off
- prr Off
- shan Off
- adi Off
- epci Off
- apn Off
- cih Off
- pmi Off
- sphic Off
- acihsf Off
- dcdmi Off
- dnr Off
- sac Off
- opnc Off
- msr Off
- hsg Off
- asii Off
- gp Off
- fpp Off
- other Off
- pttv Off
- ottv Off
- sttv Off
- ottvist Off
- oxu Off
- oxupe Off
- oufsp Off
- sh Off
- ih Off
- hd Off
- fab Off
- ug Off
- ir Off
- us Off
- nta Off
- pp Off
- mss Off
- ep Off
- ev Off
- sb Off
- adce Off
- sf Off
- ppf Off
- rma Off
- hsd Off
- ppnf Off
- dfc Off
- fpi Off
- dim Off
- imm Off
- ipp Off
- put Off
- cp Off
- ph Off
- sn Off
- ot Off
- st Off
- aid Off
- oth Off
- mfc Off
- nch Off
- oo Off
- mmc Off
- idt Off
- sse Off
- sdi Off
- ncwdo Off
- ddt Off
- eo Off
- no so-cg Off
- nancg Off
- salin Off
- 2x2 Off
- 4x4 Off
- abd Off
- telf Off
- tap Off
- wg Off
- glov Off
- ns Off
- hyd Off
- ks Off
- td Off
- oint Off
- cs Off
- ther Off
- rb Off
- ic Off
- ivsk Off
- ivp Off
- ivt Off
- as Off
- asi Off
- per Off
- et Off
- cid Off
- ip Off
- ss Off
- duo Off
- bs Off
- abs Off
- m2x11 Off
- mt2 Off
- s4x4 Off
- ng Off
- und Off
- ec Off
- ub Off
- op Off
- ow Off
- sat Off
- fol Off
- ls Off
- sc Off
- tc Off
- aa Off
- otth Off
- app Off
- chem Off
- cta Off
- dcfg Off
- hyt Off
- it Off
- syr Off
- glu Off
- es Off
- ft Off
- srk Off
- strk Off
- sstri Off
- is Off
- stst Off
- ta Off
- vg Off
- kl Off
- sr Off
- bath Off
- can Off
- com Off
- smo Off
- prd Off
- egg Off
- hb Off
- hl Off
- efp Off
- neb Off
- oc Off
- pup Off
- pui Off
- or Off
- inj Off
- ivinf Off
- inh Off
- pcbp Off
- fcc Off
- pe Off
- wcd Off
- pai Off
- doc Off
- soa Off
- injr Off
- pt Off
- sup Off
- atu Off
- qc Off
- sd Off
- cht Off
- mep Off
- ncfa Off
- dpd Off
- wdc Off
- dmc Off
- iad Off
- gc Off
- nmd Off
- trc Off
- oca Off
- fc Off
- pfv Off
- oup Off
- uhm Off
- pmh Off
- eim Off
- e911 Off
- puitc Off
- cpdv Off
- dpdp Off
- rp Off
- ko Off
- ipai Off
- iop Off
- iudp Off
- dc Off
- ds Off
- spe Off
- sfcp Off
- ispm Off
- npp Off
- fi Off
- issi Off
- cqm Off
- idc Off
- msw Off
- iicm Off
- ign Off
- ret Off
- mrw Off
- pcd Off
- dccw Off
- ort Off
- epum Off
- meac Off
- pebp Off
- iap Off
- iiph Off
- iccs Off
- ipc Off
- icdb Off
- ipm Off
- ipap Off
- eiad Off
- ipaot Off
- odit Off
- mepc Off
- ttdp Off
- scwc Off
- mr Off
- dn Off
- cef Off
- pcm Off
- si Off
- spi Off
- eplan Off
- oa Off
- nmbs Off
- tg Off
- idp Off
- ipd Off
- icid Off
- igp Off
- ief Off
- ida Off
- nss Off
- api Off
- aps Off
- pst Off
- sib Off
- sdp Off
- ippph Off
- aperi Off
- pf Off
- ap Off
- apv Off
- pa Off
- ans Off
- imb Off
- imt Off
- ewl Off
- acb Off
- mlc Off
- eob Off
- afs Off
- paa Off
- rt Off
- das Off
- got Off
- lsm Off
- dpc Off
- ils Off
- mpb Off
- iao Off
- ihc Off
- mfs Off
- ipcp Off
- tae Off
- iua Off
- tsb Off
- pc Off
- hc Off
- sp Off
- mdc Off
- oh Off
- tpr Off
- ad Off
- awa Off
- psm Off
- gs Off
- wc Off
- lhk Off
- awpc Off
- errand Off
- nlb Off
- fnc Off
- pric Off
- rsf Off
- src Off
- ebc Off
- ppt Off
- gtwa Off
- ebp Off
- eem Off
- nme Off
- nsf Off
- bmt Off
- thm Off
- tt Off
- ism Off
- ephs Off
- irle Off
- isc Off
- atp Off
- mre Off
- te Off
- pas Off
- sfe Off
- pom Off
- sad Off
- isp Off
- fsm Off
- idy Off
- vdt Off
- ar Off
- noc Off
- ldt Off
- mfa Off
- crm Off
- crp Off
- lrp Off
- mrms Off
- sps Off
- acmr Off
- hwi Off
- hdic Off
- psn Off
- dsdc Off
- usb Off
- dcw Off
- saic Off
- dptw Off
- rsm Off
- kss Off
- uhc Off
- hpa Off
- ipi Off
- grp Off
- ftcm Off
- wac Off
- ria Off
- paf Off
- pafi Off
- pwe Off
- ptc Off
- ges Off
- otp Off
- pwdf Off
- pdaf Off
- pdi Off
- pdis Off
- phas Off
- pep Off
- 12100 Off
- allepen Off
- Patient is not diabetic or is bilateral amputee
- mswref Off
- genitonoprob Off
- Urostomy describe skin around stoma Off
- nutrinoprob Off
- O2prod Off
- woraft Off
- woreve Off
- wormor Off
- worsleep Off
- prodsputcol
- fname Off
- Rehabdc1 Off
- mswgwk1
- stgwk2
- stgwk1
- stgwk3
- rhpoor Off
- Clear Form
- E-mail Form
ADLIADLs (Contd)(M1880) Current Ability to Plan and Prepare Light Meals (eg cerealsandwich) or reheat delivered meals safely
(M1845) Toileting Hygiene Current ability to maintain perineal hygienesafely adjust clothes andor incontinence pads before and after usingtoilet commode bedpan urinal If managing ostomy includes cleaningarea around stoma but not managing equipment
0 - (a) Able to independently plan and prepare all light meals for selfor reheat delivered meals OR
0 - Able to manage toileting hygiene and clothing management (b) Is physically cognitively and mentally able to prepare lightwithout assistance meals on a regular basis but has not routinely performed light
meal preparation in the past (ie prior to this home careadmission)1 - Able to manage toileting hygiene and clothing management
without assistance if suppliesimplements are laid out for the1 - Unable to prepare light meals on a regular basis due to physicalpatient
cognitive or mental limitations2 - Someone must help the patient to maintain toileting hygiene2 - Unable to prepare any light meals or reheat any delivered mealsandor adjust clothing
3 - Patient depends entirely upon another person to maintain toileting(M1890) Ability to Use Telephone Current ability to answer the phonesafely including dialing numbers and effectively using the telephone tocommunicate
hygiene
(M1850) Transferring Current ability to move safely from bed to chairor ability to turn and position self in bed if patient is bedfast 0 - Able to dial numbers and answer calls appropriately and as
desired0 - Able to independently transfer 1 - Able to use a specialty adapted telephone (ie large numbers on
the dial teletype phone for the deaf) and call essential numbers1 -Able to transfer with minimal human assistance or with use of anassistive device 2 - Able to answer the telephone and carry on a normal conversation
but has difficulty with placing calls2 -Able to bear weight and pivot during the transfer process butunable to transfer self 3 - Able to answer the telephone only some of the time or is able to
carry on only a limited conversation3 - Unable to transfer self and is unable to bear weight or pivot when4 - Unable to answer the telephone at all but can listen if assistedtransferred by another person
with equipment4 - Bedfast unable to transfer but is able to turn and position self in5 - Totally unable to use the telephonebed
NA - Patient does not have a telephone5 - Bedfast unable to transfer and is unable to turn and position self
RefusedIndications for Home Health Aide may be needed
(M1860) AmbulationLocomotion Current ability to walk safely oncein a standing position or use a wheelchair once in a seated position ona variety of surfaces
NoYesMD Order obtained
OTSN MSWOther Services ordered STPT
0 - Able to independently walk on even and uneven surfaces and
Comment
negotiate stairs with or without railings (ie needs no humanassistance or assistive device)
1 - With the use of a one-handed device (eg cane single crutchhemi-walker) able to independently walk on even and uneven sur-faces and negotiate stairs with or without railings
2 - Requires use of a two-handed device (eg walker or crutches) to(M1900) Prior Functioning ADLIADL Indicate the patients usualability with everyday activities prior to this current illness exacerbationor injury Check only one box in each row
walk alone on a level surface andor requires human supervisionor assistance to negotiate stairs or steps or uneven surfaces
3 - Able to walk only with the supervision or assistance of another
Functional Area IndependentNeeded
Some HelpDependent
a Self-Care (eg groomingdressing and bathing) 0 1 2
b Ambulation 0 1 2
c Transfer 0 1 2
d Household tasks (eglight meal preparationlaundry shopping)
0
1 2
person at all times
4 - Chairfast unable to ambulate but is able to wheel selfindependently
5 - Chairfast unable to ambulate and is unable to wheel self
6 - Bedfast unable to ambulate or be up in a chair
(M1870) Feeding or Eating Current ability to feed self meals andsnacks safely Note This refers only to the process of eating chewinqand swallowing not preparing the food to be eaten
0 - Able to independently feed self
ACTIVITIES PERMITTED
1 - Able to feed self independently but requires(a) meal set-up OR(b) intermittent assistance or supervision from another person OR(c) a liquid pureed or ground meat diet 8-Crutches1 -Complete bedrest
9-Cane2-BedrestBRP2 -Unable to feed self and must be assisted or supervisedA-Wheelchair3-Up as toleratedthroughout the mealsnackB-Walker4-Transfer bedchair3 - Able to take in nutrients orally and receives supplemental nutrientsC-No restrictions5-Exercises prescribedthrough a nasogastric tube or gastrostomy
D-Other (specify)6-Partial weight bearing4 - Unable to take in nutrients orally and is fed nutrients through anasogastric tube or gastrostomy
7-Independent in home5 - Unable to take in nutrients orally or by tube feeding
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Patient Name Med Record
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If the patient experiment-ADLIADL Deficit - Elimination Deficit - Impaired Mobility
18BCMS 485 (POC)
PatientFamily
NA (Home Health Aide Services not needed)
(SOC)
(M1910) See previous page 13 before the FALL RISK ASSESSMENT
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ALLERGIES MEDICATIONS(M2040) Prior Medication Management Indicate the patients usualability with managing oral and injectable medications prior to this currentillness exacerbation or injury Check only one box in each row
None known NKA AspirinSulfaPollens and mold spores
EggsPenicillin
Insect bitesDairyMilk products
Functional Area Independent NeededSome Help Dependent Not
Applicable
a Oralmedications 0 1 2 na
b Injectablemedications 0 1 2 na
Other
MEDICATIONS
(M2000) Drug Regimen Review Does a complete drug regimen reviewindicate potential clinically significant medication issues eg drugreactions ineffective drug therapy side effects drug interactionsduplicate therapy omissions dosage errors or noncompliance
0 - Not assessedreviewed [Go to M2010]
1 - No problems found during review [Go to M2010]
2 - Problems found during reviewNA - Patient is not taking any medications [Go to M2040]
INFUSION IV THERAPYNA
(M2002) Medication Follow-up Was a physician or the physician-designee contacted within one calendar day to resolve clinicallysignificant medication issues including reconciliation
Peripheral line Central line
Typebrand
0 - No
Size
1 -Yes
Non-tunneledGroshong Non-Groshong TunneledInsertion site Insertion date
(M2010) PatientCaregiver High Risk Drug Education Has the patientcaregiver received instruction on special precautions for all high-riskmedications (such as hypoglycemics anticoagulants etc) and how andwhen to report problems that may occur
Lumens DoubleSingle TripleFlush solution
YesPatent N o
0 - No
Injection cap change frequency
1 -Yes
Dressing change frequency
NA - Patient not taking any high risk drugs OR patientcaregiver fullyknowledgeable about special precautions associated with allhigh-risk medications
Sterile CleanPatient RNPerformed by Caregiver Other
Siteskin condition
(M2020) Management of Oral Medications Patients current ability toprepare and take all oral medications reliably and safely includingadministration of the correct dosage at the appropriate timesintervalsExcludes injectable and IV medications (NOTE This refers to abilitynot compliance or willingness)
External catheter lengthOtherComment
0 - Able to independently take the correct oral medication(s) and
PICC Specific
proper dosage(s) at the correct times
Circumference of arm
1 - Able to take medication(s) at the correct times if
X-ray verificationYes No
(a) individual dosages are prepared in advance by another personOR
IVAD Port Specific
(b) another person develops a drug diary or chart
Reservoir DoubleSingle
2 - Able to take medication(s) at the correct times if given reminders
Huber gaugelength
by another person at the appropriate times
NoAccessed Yes date
3 - Unable to take medication unless administered by another person
EpiduralIntrathecal Access
NA - No oral medications prescribed
Siteskin condition
(M2030) Management of Injectable Medications Patients currentability to prepare and take all prescribed injectable medications reliablyand safely including administration of correct dosage at the appropriatetimesintervals Excludes IV medications
Infusion solution (typevolumerate)DressingOtherComment
0 - Able to independently take the correct medication(s) and properdosage(s) at the correct times
1 - Able to take injectable medication(s) at the correct times if
IV-Infusion Medication(s) administered
(a) individual syringes are prepared in advance by another
Drug Name
person OR
RouteDose
(b) another person develops a drug diary or chart
Frequency Duration of therapy
2 - Able to take medication(s) at the correct times if given remindersby another person based on the frequency of the injection
IV-Infusion Medication(s) administered
3 - Unable to take injectable medication unless administered by
Drug Name
another person
Dose Route
NA - No injectable medications prescribed
Frequency Duration of therapy
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Patient Name Med Record
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Financial ability to pay for medications Yes No
Was MSW referral made Yes
CommentPlan
Infusion IV Therapy order obtained verified
Gauge Length
Frequency
Iodine
Medline catheter
No
- Unsafe Living Environment -Pt demo unsafe behavior or choices - Limited Resources -At risk and lives alone -Pt is CG for another Yes No
Intravenous IV Port Yes No Flush Ordered Yes NoLast flushed date(vascular access device)
IV Therapy complication observed Pain amp irritation Infiltration amp exravasionOcclusionobstruction fluid overload Other
Dust mitesAnimal dander and urine
(SOC)
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INFUSION IV THERAPY (Contd)
Infusion care provided during visitPump (type specify)OtherCaregiverPatient RNAdministered by
Purpose of Intravenous Access
Pain control
Lab drawsInterventions Instructions Comments Problems DetectedAntibiotic therapy
Maintain venous accessChemotherapyParenteral nutrition (TPN)HydrationOther
CARE MANAGEMENT
(M2100) Types and Sources of Assistance Determine the level of caregiver ability and willingness to provide assistance for the following activitiesif assistance is needed (Check only one box in each row)
Caregiver(s)Caregiver(s) Unclear ifNeed TrainingCaregiver(s) AssistanceNo Assistance Not Likely toCurrently Supportive Caregiver(s) Needed ButType of Assistance Needed in This Provide ProvideServices to Will Provide No Caregiver(s)Area Assistance AssistanceAssistance Provide Available
Assistance
a ADL Assistance (egtransferambulation bathingdressing toileting eatingfeeding)
0 1 2 3 4 5
b IADL Assistance (egmeals housekeepinglaundry telephone shoppingfinances)
0 1 2 3 4 5
c Medication Administration(eg oral inhaled orinjectable)
0 1 2 3 4 5
d Medical ProceduresTreatments (eg changingwound dressing)
0 1 2 3 4 5
e Management of Equipment(includes oxygen IVinfusionequipment enteralparenteralnutrition ventilator therapyequipment or supplies)
0 1 2 3 4 5
f Supervision and Safety(eg due to cognitiveimpairment)
0 1 2 3 4 5
g Advocacy or Facilitation ofpatients participation inappropriate medical care(includes transportation to orfrom appointments)
0 1 2 3 4 5
(M2110) How Often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)1 - At least daily 4 - Received but less than weekly
5 - No assistance received2 - Three or more times per weekUK - Unknown3 - One to two times per week
APPLIANCES SPECIAL EQUIPMENT HOME MEDICAL EQUIPMENT Co
Needs (specify)BraceOrthotics (specify)
Bedside commodeTransfer equipment BoardLift Oxygen HME Co
Prosthesis RUE RLE LUELLEOther HME Rep
Grab bars BathroomOther
PhoneOrganizations providing Home Medical Equipment (HME)
Hospital bed Semi-elec Crank SpecLifeline
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Patient Name Med Record
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Ostomy Pliers Shower chair Scooters Hoists
Wheeled Walker Other Phone NA
NA
Removing line date (if know)
Expand intravascular volume
Blood and its derivativesNA
NA
NA
(SOC)
SGFire PreventionSafety Program in place Patient instructed
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SAFETY MEASURES LIVING ARRANGEMENTS SUPPORTIVE ASSISTANCE
Oxygen use NYSigns postedYFollow smoking flammables safety precautions N
Oxygen back-up Knows Instructed how to useAvailable
Oxygen Precautions explained
PlanComments
Safety hazards in the home (check all that apply)NYFire alarmsmoke detector Fire extinguish
Inadequate heating cooling electricity lightingHurricane Disaster Emergency supplieskits
NY
InstructionsInformation Provided Sign Up package (Check all that apply)
Y N
Patient Rights and responsibilities
NYFirst aid boxEmergency Equipment or Supplies
State hotlineABUSE number
NYUnsafe gaselectrical appliances or electrical outlets
Advance directives information
NYInadequate running water plumbing problemsDo not resuscitate (DNR) (if applicable)NUnsafe storage of supplies equipment HME
No telephone available andor unable to use the phonePest problems InsectsrodentsMedications stored safely clearly-easy use check interactions
Service AgreementContractNYOASISHIPAA Privacy Notice ConfidentialityNY
Emergency Plan classification instructionsNYAgency phone numbers addressEmergency planning Exit Plan in place more than one exitClient Information Handbook
Y N
Standard precautions handwashing Infection Control
NYEnough Ventilation
Home safety guidelines
Safe BedsChairs clear pathways
Admission criteria Information for Home visit Services FrequencyY NAble to follow directions in case of Emergency
Diabetes Control other disease management informationNYSlippery Floors Ashtrays (if a smoker)
Fall Prevention Program
NYPlan for power failure emergency lights flashlights etc
THERAPY AND PLAN OF CARE(M2200) Therapy Need in the home health plan of care for the Medicarepayment episode for which this assessment will define a case mixgroup what is the indicated need for therapy visits (total of reasonableand necessary physical occupational and speech-language pathologyvisits combined) (Enter zero [000] if no therapy visits indicated)
) Number of therapy visits indicated (total of physicaloccupational and speech-language pathology combined)
(
NA - Not applicable No case mix group defined by this assessment(M2250) Plan of Care Synopsis (Check only one box in each row) Does the physician-ordered plan of care include the following
PlanIntervention YesNo Not Applicable
a Patient-specific parameters for notifying physician ofchanges in vital signs or other clinical findings 0 1 na
Physician has chosen not to establish patient-specific parameters for this patient Agency will usestandardized clinical guidelines accessible for allcare providers to reference
b Diabetic foot care including monitoring for the presence ofskin lesions on the lower extremities and patientcaregivereducation on proper foot care
0 1 naPatient is not diabetic or is bilateral amputee
c Falls prevention interventions 0 1 na Patient is not assessed to be at risk for falls
d Depression intervention(s) such as medication referral forother treatment or a monitoring plan for current treatment 0 1 na Patient has no diagnosis or symptoms of
depression
e Intervention(s) to monitor and mitigate pain 0 1 na No pain identified
f Intervention(s) to prevent pressure ulcers 0 1 na Patient is not assessed to be at risk for pressureulcers
g Pressure ulcer treatment based on principles of moistwound healing OR order for treatment based on moistwound healing has been requested from physician
0 1 naPatient has no pressure ulcers with need for moistwound healing
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Y
NY
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Patient Name Med Record
HOME ENVIRONMENT SAFETY
NYRelevant medical appliances if applicable ( wheelchair O2 Monitors etc)NYHurricane Shutter Disaster Plan
Medication sheet reconciliatedchecked
Alzheimers Sensory impairments info
Care Plans
Pain Management info Grievance Procedures
Local Resources Guide Mission ownership information
Physical Therapy Total visitsOccupational Therapy Total visits
Speech Therapy Total visitsOther Therapy Total visits
(SOC)
Safety Measures CMS485 (POC)
Cast PrecautionsChange position slowlyCoumadinHeparin PrecautionsDo not lift bend stoopGood handwashing techniqueOxygen PrecautionFire preventionPractice Universal Precautions
15
Safe Ambulation
Respiratory PrecautionsDiabetic PrecautionsWoundDecubitus precautionsAdequate lightingPrevent Cardiac OverloadPrevent Falls and Injuries GI Precautions
Prev Infection ComplicationsSeizure PrecautionsSuicide precautionsSupport due functional limitationTeach coping skillsSafe storagedisposal syringes Cardiac Precautions
GU Precautions
Safe TransfersSAN PrecautionsCatheter CareProvide Emotional SupportEmergency Plan
Maintain Safeclear EnvironmentMaintain Good Skin care
Clear pathways
Other
SG
Correct handwashing technique SG
Check bathroom floorstairs for safety hazardsPsycho-social behavior precautions
SG
SGSG
SG
SG
SG
Other
SG
SG
SG
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PATIENT CARE COORDINATION
CARE PLAN Reviewed with patient involvementOrder obtainedMedication Form completedreviewedupdated No changeMEDICATION RECORD
Ineffective drug therapySignificant drug interactions
Significant side effectsNon-compliance with drug orders Duplicate drug therapy
Other (specify)M S WSNPhysician AidePT OT STCARE COORDINATION
Explain
Yes No
DME SUPPLIES
IV start kit Underpads size BathbenchChemstrips2x2sIV pole
External catheters
Syringes Cane Quad CaneIV tubing
Urinary bagpouch
COTTON TIP APP4x4s
CommodeAlcohol swabs
Ostomy pouch (brand size)
Special mattress overlayABDs
Angiocatheter size
Cotton tipped applicatorsPeroxide Ostomy wafer (brand size)
Pressure relieving device
Wound cleanserExtension tubingsWound gel
Injection caps
Stoma adhesive tape
Eggcrate
Drain sponges Central line dressing
Skin protectant
Hospital bed
GlovesNon-sterile
Side Rails
Infusion pump Hoyer lift
Sterile Batteries size Enteral feeding pump
Hydrocolloids
Enema suppliesSyringes size
Nebulizer
Kerlix size
Feeding tubeNu-gauze
MEFIX 2X11 YD (EA)
Oxygen concentrator
sizetype Suction machine
SalineNSS
FOLEYCATH SUPPLIES
Suture removal kit Ventilator
Tape
Fr catheter kit
Staple removal kit Walker
(tray bag foley)Transparent dressings
Steri strips
Straight catheter
Wheelchair
Ointment
TRIPLE ANTIBIOTIC 30GR
Irrigation tray
Tens unitSalineNSS
OtherAcetic acid
Other
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Patient Name Med Record
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14
PATIENTCAREGIVER INSTRUCTIONS-TEACHINGCheck all that appliesPatientcaregiver(CG) independent with
Trach care
N oYesWoundDecubitus care
Yes No
Yes N o
Ostomy care Yes
N oYesDiabetic managementcare
N o
N oYesNoYesInsulin administration N oYes
Oxygen useprecautions
Yes N oGlucometer usecalibration N oYes
Use of home medical equipmentdevices
N oYesNutritional managementDiet
NoCaregiver present during the visit Yes
PatientCG educationteaching this visit for
N oYesPatientCG able to understand instructionsteaching
Does the patientCG have a plan when disease symptoms exacerbate (eg when to call the nurseAgency vs emergency 911) N oYes
Comment(s)
SKILLED CARE PROVIDED THIS VISIT
Medication management Administration Oral Injection IV-Infused Inhaled
Foley care Yes N o
Pain ManagementHome prescribed exercisesActivities of Daily LivingPersonal Care
MEDICATION
DISEASE PROCESS COMPLICATIONSSS OFILEAL CONDUITOSTOMY SKINFOOT CAREDIET FLUIDS INFECTION CONTROL
OTHER INSTRUCTIONS GIVEN
N oYesElimination Incontinence management
NEEDS FURTHER TEACHINGExplain
NA NANANANANA
NANANANANANANA
Yes N oPhysician follow up visitsappointments NA
Expected Outcome
DISCHARGE PLANNING DISCUSSEDEXPLAINED Patient unable to perform own Wound Care dueto
Patient unable to InsulineInjection self administration dueto
No SO or CG ablewilling for wound careInsulin-Injection administration at this time
Telfa
Colostomy Supplies
Thermometer
Texas Cath
Red Box (Biohazard)
Betadine Solution
Abd Pads
Duoderm
Sharp Container
Ace band size
Leg Straps Cath
ALCOHOL PREP PADS
DUODERM CFGHY-TAPE 2INSERTION TRAY 5CC
INSULIN SYRINGE ____ CCSYRINGES
Glucometer
MICROPORE TAPE 2
SOFTWICK 4X4
VASELINE GAUZE 3X9
KLING 4
(SOC)
Medication Management Check all that appliesidentified Potential adverse effectsdrug reactionsSG
Skil led Observation AssessmentINJECTION ROUTE_______ SITE _____ MED GIVEN ______________________ DOSE __________ REACTION _____________________________
Foley ChangeCare Patient Educationteaching Wound Care Dressing Change Prep Admin Insulin
StandardUniversal Precautions Followed Aseptic Tech Used Quality Control of Glucometer Performed Sharps Discarded Inside Sharps Container
ProcedureTx welltolerated by Pt
Diabetic Observation Care
Correct handwashing technique followed SG ManagementEvaluation Patients Care Plan No caregiverfamily availablewilling to help patient with care procedures
SG
Pshycological carebehaviour problems prevention NA
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Orders by discipline (optional) To complete CMS485 (POC)
SN - ORDERS - FREQUENCYDURATION
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Patient Name Med Record
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21
OTHER
General
Psychiatric
F o l e y Care
REPORT ANY ELEVATIONS IN TEMPERATURE TO THE MD
Wound CareDecubitus
IMPROVE THE PTS ABILITY TO PREVENT OR COPE WITH BREATHING DIFFICULTIES
Asthma Respiratory
INST FOR SS EASY FATIGABILITY DYSPNEA PALPITATIONS ANGINA TACHYCARDIAPALLOR DIZZINESS JAUNDICE AND FEVER INST FOR G I DISTURBANCES ASSESS FOR CENTRALNERVOUS SYSTEM SYMPTOMATOLOGY OBTAIN APPROPRIATE LAB TESTS AND REPORT FINDINGS TO MD ADMINISTER PRESCRIBED INJECTABLE _________________ USING ______ TECHNIQUE
Anemia
Included as reference only your Professional Staff must reviewupdatepersonalizedapprove the orders
INSTRUCT IN PREPARATION amp ADMINISTRATION OF INSULIN INSTRUCT ONSET PEAK ampDURATION OF ACTION OF INSULIN INSTRUCT PROPER DISPOSAL OF SYRINGESNEEDLES NURSE TO MONITOR BLOOD SUGAR WITH GLUCOMETER OR ___________ON __________FREQUENCY ampNOTIFY MD OF ALTERED RESULTS TEACH GLUCOMETER OR __________ PROCEDURE amp INTERPRETING RESULTS
InsulinGlucometer
INST DISEASE PROCESS amp COMMON COMPLICATIONS INST PRESCRIBED DIET amp SHOPPING ADVICE INST SSHYPOHYPERGLYCEMIA amp EMERGENCY PROCEDURES INST GOOD SKIN CARE amp GOOD FOOT CARE DAILY CARE OFTEETH INST DIABETIC CHART INST SampA TESTING amp READING RESULTS INSTRUCT TO CARRY ID THAT INCLUDESINFORMATION REGARDING DIABETIC STATUS NAMES amp DOSAGE OF MEDS amp ACTION TO TAKE IF INSULIN REACTION OCCURS INST IMPORTANCE OF GOOD PERSONAL HEALTH HABITS INCLUDING EXERCISE ADEQUATEREST SLEEP REGULAR MED CHECK-UPS (INCLUDING PODIATRIC OPTHAMOLOGIST amp DENTIST)
DiabetesMellitus
INST PACED ACTIVITY PROGRAM
OBSERVE FOR SS OF DECOMPENSATION SUCH AS INCREASING TACHYCARDIA WSUDDEN ONSET SOB ON MINEXERTION ORTHOPNEA EXTREME ANXIETY PROGRESSIVE CYANOSIS GENERALIZED PALLOR AND DIAPHORESISCHF
INSTRUCT PROPER ADMINISTRATION OF OXYGEN THERAPY INSTRUCT OXYGEN PRECAUTIONSINSTRUCT MAINTENANCE OXYGEN EQUIPMENTOxygen
ASSESS FOR CHEST PAIN TYPE LOCATION INTENSITY DURATION amp FREQUENCY IS PAINMANAGEMENT NOTIFY MD IF PAIN PERSISTS IS GRADUAL PROGRESS ACTIVITY INCREASEINST DISCONTINUE ACTIVITY IF CHEST PAIN DYSPNEA FATIGUE OR PALPITATIONS OCCUR
Angina
PSYCHOLOGICAL ASSESSMENT ASSESS NEUROLOGICAL STATUS IMPLEMENT AND MONITOR BOWEL REGIMEN ampTEACH PROGRAM TO FAMILY SN TO MONITOR TRANQUILIZER EFFECTS GIVEN FOR SEVERE AGITATIONANXIETYEVALUATE FOR WEIGHT LOSS WEIGH PATIENT Q VISIT AND RECORDS WEIGHTS MONITOR LEVEL OFCONSCIOUSNESS ASSESS COORDINATION AND BALANCE PROVIDE EMOTIONAL SUPPORT TO PATIENT ANDFAMILY OBSERVATION AND EVALUATION OF BLADDER ELIMINATION HABITS MANAGEMENT IF INCONTINENCEASSIST FAMILY IN SETTING UP ROUTINE PATIENT-CENTERED AND STRESS THE IMPORTANCE OF ADHERING
Alzheimers
AIDE - ORDERS - FREQUENCYDURATIONTUBSHOWER BATH PERSONAL CARE HAIR COMB SHAMPOO PRN MOUTHDENTURE CARE SKIN CHECK ORAL HYGIENE TPRASSIST TO DRESS ASSIST WITH AMBULATION PREPARE SERVE MEALS GROCERY SHOP WASH CLOTHES LIGHT HOUSEKEEPING ASSIST WITH PERSONAL CARE AND ADLSERRANDS NOTIFY LAST BM IF NONE FOR 3 DAYS FEETNAILS CARE PERI CARE REPORT SIGNIFICANT FINDING TO SN STRAIGHTEN ROOM amp CHANGE LINEN
PT - ORDERS - FREQUENCYDURATIONEVALUATE BALANCE AND COORDINATION EVALUATE ENDURANCE MOBILITY NEUROMUSCULAR RE-EDUCATIONPERFORM PRESCRIBED THERAPEUTIC EXERCISES NOTIFY SIGNIFICANT FINDING TO MDAGENCY BED MOBILITY TRAININGGAIT TRAINING WITH ASSISTIVE DEVICE TEACH HOME MAINTENANCE PROGRAM AND STRENGTHENING EXERCISEEXERCISE BOTH PASSIVE AND ACTIVE EXERCISE REGIMEN TRANSFER TRAINING INSTRUCT IN SAFETY MEASURES FALL PRECAUTIONS
OT - ORDERS - FREQUENCYDURATIONEVALUATE PATIENT AND HOME FOR SAFETY ADL TRAINING PROGRAM MUSCLE RE-EDUCATION BODY IMAGE TRAININGINCREASE RIGHT AND LEFT UPPER EXTREMITIES STRENGTH THERAPEUTIC EXERCISE TO (R) AND (L) HANDINCREASE STRENGTH AND COORDINATION PROPRIOCEPTION AND SENSATION
ST FOR EVALUATION TO PROVIDE ORAL MOTOR EXERCISES INVOLVING LINGUAL AND LABIAL EXERCISES SPEECH ARTICULATION DISORDER TREATMENTIMPROVE SPEECH FACIAL SYMMETRY AND MUSCULATION IMPROVE DYSPHAGIA VOICE DISORDER TREATMENT AURAL REHABILITATION NON-ORAL COMMUNICATION LANGUAGE DISORDER TREATMENT
ST - ORDERS - FREQUENCYDURATION
MSW - ORDERS - FREQUENCYDURATIONMSW FOR ASSESSMENT OF SOCIAL AND EMOTIONAL FACTORS COMMUNITY RESOURCE PLANNINGCOUNSELING REGARDING MANAGEMENTADJUSTMENT TO ILLNESS LONG RANGE PLANNING AND DECISION MAKING
PROVIDE SUPPORTIVE AND RELAXATION THERAPY PROVIDE FAMILY THERAPY ASSESS INTERPERSONALBEHAVIOR ASSIST PATIENT TO DEFINE PROBLEMS amp SOCIAL RELATIONSHIPS GIVE POSITIVE REINFORCEMENTASSIST PATIENT TO VERBALIZE FEELINGS
Anxie ty
INST DISEASE PROCESS AND COMMON COMPLICATIONS INST LOW SODIUM DIET - STRESSING IMPORTANCE OFADHERENCE MONITOR PATIENTS BLOOD PRESSURE CLOSELY AND NOTIFY MD OF ANY SIGNIFICANT CHANGESINSTRUCT PT TO AVOID OVER-THE-COUNTER COLD AND SINUS MEDS AS THEY CONTAIN VASOCONSTRICTORINST OF HYPERTENSIVE CRISIS MONITOR FOR SS OF ORTHOSTATIC HYPOTENSION
Hypertension
ASSESS PSYCHOLOGICAL STATUS PROVIDE SUPPORTIVE THERAPY PROVIDE REMOTIVATION ASSESSINTERPERSONAL BEHAVIOR ASSIST PATIENT TO DEFINE PROBLEMS amp SOCIAL RELATIONSHIPS GIVE POSITIVEREINFORCEMENT ENCOURAGE PATIENT TO PERFORM PERSONAL HYGIENE amp GROOMING ACTIVITIESASSIST PATIENT TO EXPRESS REALISTIC IDEAS amp PLANS ASSIST PATIENT TO VERBALIZE FEELINGS
Depression
INSTRUCT PATIENT IN CONSEQUENT PHYSICAL L IMITATIONS PLANNING AN ADEQUATE LEVEL OF DAILYACTIVITIES TEACH PT RE ARTHRITIS SS OF EXACERBATION TEACH THE IMPORTANCE OF GOOD POSTUREPREVENT TRAUMA TO JOINTS INST PT IN THE USE OF ASSISTIVE DEVICE AS PRESCRIBED
Osteoarthritis
SKILLED OBSERVATIONEVALUATION ASSESS VITAL SINGS amp SS COMPLICATIONSINSTRUCTEVALUATE UNDERSTANDING OF DISEASE PROCESS DETECTING COMPLICATIONSDIETNUTRITIONAL STATUS SAFETY PRECAUTIONEMERGENCY MEASURES MED-REGIMEN
PSYCH ASSESSMENT ASSESS FOR SS OF EPSDETECT AND ALLEVIATE SOMATIZED COMPLAINTSLIMIT SETTING MOTIVATION TECHNIQUES IMAGERY TECHNIQUES
RELAXATION TECHNIQUESGOAL ORIENTED TASKS
FOLEY INSERTION _______FR FOLEY WITH___________cc BALLONCHANGE Q MONTH amp PRN x3 FOR CLOGGED LEAKING OR ACCIDENTAL REMOVALINST DRESSING CHANGES ________________________ MONITOR FOR SS COMPLICATIONS amp NOTIFY MD
INST SS INFECTION
MONITOR STATUS OF WOUND OR DECUBITUS (place) ______________INST INFECTION CONTROL MEASURES
INST GOOD NUTRITION TO FACILITATE HEALINGMEASURE AND RECORD WOUND or DECUBITUS SIZE AT SOC AND AT LEAST WEEKLY THEREAFTEROPEN WOUND CAREDRESSING CLEANSE WOUND WITH ___________ TO RINSE WITH __________ AND APPLY______________ AND PRN
OBSERVE AND RECORD TYPE AND AMOUNT OF DRAINAGE COLOR INFECTION SWELLING REDNESS PAINDE CUB ITUS CAR EDR ESS ING CLEAN SE W OUN D WITH ___________ TO R IN SE WITH __________ AN D APP LY ______________ AN D PR N
TEACH THE PATIENT HOW TO USE A METERED-DOSE INHALER MAINTAIN EFFECTIVE AIRWAY CLEARANCE
EMPHASIZE THE IMPORTANCE OF ADEQUATE DAILY FLUID INTAKE
PROMOTE AN EFFICIENT BREATHING PATTER
INST INFECTION CONTROL amp PULMONARY HYGIENE INST COMPLICATIONS IN CARDIOPULMONARY STATUSINST PREVENTION OF COMPLICATIONS IE AVOID OVER-EXERTION CHILLING CROWDS ETC
INST D ISEASE PROCESS amp MAINTENANCE
INSTRUCT COUGHING DEEP BREATHING EXERCISES INST PATIENT TO MAINTAIN ADEQUATE REST PATTERN
MANAGEMENT AND EVALUATION OF A PATIENT CARE PLAN TEACHING AND TRAINING DISEASE PROCESS SKIN CARE WOUND CAREDRESSING CHANGE DECUBITUS CARE MEDICATION REGIMEN DIETNUTRITIONHYDRATION COMPLICATIONS OF ENT FEEDING AS INDICATED
PAIN CONTROL MEASURES SYMPTOM CONTROL MEASURES SINGSSYMPTOMS OF INFECTION SAFETYPREVENTION OF INJURY EMERGENCY PLANS OXYGEN ADMINISTRATION
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GOALSREHABILITATION POTENTIAL CMS485 (POC)Included as reference only your Professional Staff must reviewupdatepersonalizeapprove the goals
DISCHARGE PLANNING DISCUSSED WITH PATIENT Yes No REHAB POTENTIAL ExcellentPoor Fair Good
SIGNATUREDATES
X DateStaff Completing the OASIS (signaturetitle)
OASIS INFORMATION
Data Entry Date amp Locked Date SubmittedQA Date Reviewed
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SN - GOALSMRMS _________________ WILL EXHIBIT VITAL SIGNS WITHIN ACCEPTABLE RANGE AND STABILIZED DISEASE PROCESSVERBALIZES KNOWLEDGE OF DISEASE MANAGEMENT MEDICATIONS SIDE EFFECTS PRECAUTIONS DIET FLUIDS TREATMENT PROGRAM SS NECESSITATING MEDICAL ATTENTION EMERGENCY CARE
STABILIZATION OF PSYCHOLOGICAL STATUS WITHIN DISEASE LIMITS TO REDUCE THE PATIENTS ANXIETY LEVELDEPRESIONANXIETY CONTROLED TROUGH MED REGIMEN INTERVENTIONS
ANEMIA CONTROLLED THROUGH MED REGIMEN IMPROVED HEMATOLOGIC STATUS
General
Psychiatric
A n e m i aHEALED WOUND WITHOUT INFECTION OR COMPLICATIONS DEMONSTRATE PROPER WOUND CARE
Wound Care
PTSO SHOULD UNDERSTAND THE NATURE SYMPTOMS STAGE AND PROGRESSION OF ALZHEIMERS DISEASEKNOW HOW TO RECOGNIZE PTS OWN STRESS AND WAYS TO PREVENT OR REDUCE IT PROMOTE SOCIAL INTERACTION AS TOLERATED BY THE PATIENT
Decubitus
DEMONSTRATE STRATEGIES TO BE USED DURING A COUGHING EPISODE HELP THE PATIENT IDENTIFY FACTORSTHAT MAY CAUSE ASTHMA ATTACKS OR CONTRIBUTE TO THEMAsthma
SAFELY ADMINISTERS INJECTION COMPREHEND RATIONALE FOR AND IS ABLE TO ROTATE INJECTION SITESCOMPREHEND SAFETY FACTORS IN SYRINGENEEDLE DISPOSALPATIENTCG ABLE TO MONITOR BLOOD SUGAR CORRECTLY WITHOUT ASSISTANCEABLE TO NOTIFY MD OF ALTEREDOUT OF RANGE RESULTS
InsulinGlucometer
DISCHARGE PT WHEN BLOOD SUGARS ARE WITHIN THE NORMAL FOR PATIENT RANGEKNOW THE ACCEPTABLE RANGE FOR BLOOD SUGAR LEVEL COMPLY WITH DIET RESTRICTIONS Diabetes
MellitusRETURN TO SELF-MANAGEMENT OF HEALED FRACTURED
FractureKNOW ABOUT SIGNS SYMPTOMS AND PRECIPITATING CAUSES OF CHF KNOW HOW TO TAKE THE PULSE AND KNOWTO CONSULT THE DOCTOR BEFORE CONTINUING MEDICATION IF THE PULSE RHYTHM CHANGES KNOW TOA V O I D S M O K I N G A N D S M O K Y E N V I R O N M E N T S A N D P E R S O N S W I T H I N F E C T I O N S E S P E C I A L L Y R E S P I R A T O R Y I N F E C T I O N S
CHF
UNDERSTAND THAT HYPERTENSION IS A CHRONIC DISEASE REQUIRING LIFE LONG TREATMENT EXHIBIT BLOODPRESSURE READINGS CONSISTENTLY WITHIN NORMAL OR SPECIFIED RANGE DEMONSTRATE ADHERENCE TO ALOW-SALT LOW-FAT DIET
Hypertension
HELP THE PATIENT ACHIEVE PAIN RELIEVE AND REDUCE ANGINA EPISODES UNDERSTAND THE CAUSE OFANGINA PECTORIS AND POSSIBLE PRECIPITATING FACTORS FOR AN ATTACK IDENTIFY PERSONAL STRESSORSTHAT MAY CONTRIBUTE TO THE PROBLEM AND BEGIN ELIMINATING OR MINIMIZING THEM KNOW WAYS TOREDUCE THE FREQUENCY OF ANGINA EPISODES
Angina
HEALED DECUBITUS WITHOUT INFECTION OR COMPLICATIONS DEMONSTRATE PROPER DECUBITUS CARE
Alzheimers
UNDERSTAND SS OF BRONCHITIS OR OTHER RESPIRATORY INFECTION AND DISEASE EXACERBATIONUNDERSTAND THE DANGERS OF SMOKING AIR AND CHEMICAL POLLUTANTS AND RESPIRATORY INFECTIONUNDERSTAND AND PRACTICE COUGHING AND DEEP-BREATHING EXERCISES
Respiratory
DAILY COMPLIANCE WCATHETER CARE DECREASE RISK OF URINARY INFECTIONCatheter
INCREASED PAIN RELIEF INCREASED STRENGTH AND ENDURANCE COMPREHEND AND DEMONSTRATE HOME EXERCISEOsteoarthritis
AIDE - GOALS
GAIT PATTERN ENDURANCE STRENGTH AND BALANCE WILL IMPROVE AND PATIENT WILL DEMONSTRATECORRECT BODY MECHANICS WIN 4-6 WKS PTCG WILL COMPREHEND AND DEMONSTRATE HOME EXERCISEPROGRAM WITHIN 4-6 WKS
FAIR-TO BE ABLE TO CARRY OUT MINIMAL ADLS WITH AVAILABLE HOME SUPPORTWILL NOT BE ABLE TO CARRY OUT ADLS WITHOUT MAXIMUM SUPPORT
RETURN TO INDEPENDENT AMBULATION BE SAFE IN SELF CAREPATIENT WILL BE ABLE TO FUNCTION WITH ASSISTANCE OF CAREGIVERWITHIN HESHE CURRENT LIMITATIONS AT HOME
PATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HISHER CURRENT LIMITATIONS AT HOME
PT - GOALS
GOOD RETURN TO PREVIOUS LEVEL OF ADLS INDEPENDENTLY
GAIT PATTERN ENDURANCE STRENGTH AND BALANCE WILL IMPROVE AND PT WILL DEMONSTRATECORRECT BODY MECHANICS WITHIN _____ WEEKS
PATIENT WILL EXPERIENCE A DECREASE IN PAIN
PTCG WILL COMPREHEND AND DEMONSTRATE HOME EXERCISEPROGRAM WITHIN _____ WEEKS
OT PATIENT WILL EXHIBIT IMPROVEMENT IN COPING IN ADLSIADLS MUSCLE USEMOTORCOORDINATIONNEURO RESPONSEUSE OF ORTHOTIC SPLINTING ANDOR EQUIPMENT
OT - GOALS
PATIENT WILL DEMONSTRATE FUNCTIONAL COMMUNICATIONS EXHIBIT MAXIMUM VERBAL AND SENTENCEFORMULATION AND COMPREHENSION WITHIN DISEASE LIMITS WITHIN _____ WEEKS
ST - GOALS
PATIENT WILL DEMONSTRATE APPROPRIATE USE OF FUNCTIONAL VERBALNON-VERBALCOMMUNICATIONS SYSTEMS WITHIN _____ WEEKS
PATIENT WILL DEMONSTRATE IMPROVED READINGWRITING USE OF GESTURESNUMBERS WITHIN _____ WEEKS
PATIENT WILL DEMONSTRATE IMPROVED SWALLOWINGCHEWINGORALMOTOR CONTROL WITHIN _____ WEEKS
PATIENT WILL HAVE ADEQUATE SUPPORT TO REMAIN IN HOME WITH ASSISTANCE OF COMMUNITYRESOURCES FOR FINANCIAL TRANSPORTATION AND PERSONAL CARE ASSISTANCE WITHIN _____ WEEKS
MSW - GOALSPSYCHOSOCIAL EVALUATION WILL BE PERFORMED PTCG WILL BE COUNSELED REGARDING MANAGEMENTamp ADJUSTMENT TO ILLNESS LONG TERM PLANNING AND DECISION MAKING APPROPRIATE COMMUNITYRESOURCE REFERRALS WILL BE MADE
WILL DISCHARGE THE PATIENT WITHIN 60 DAYS WHEN PATIENT ANDORCAREGIVER ISARE ABLE TO DEMONSTRATE KNOWLEDGE OF DISEASE MANAGEMENT SS COMPLICATIONSPATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HISHER CURRENT LIMITATION AT HOME
ABLE TO REMAIN IN HOMERESIDENCEALF WITH ASSISTANCE OF PRIMARY CAEGIVERSUPPORT AT HOMEABLE TO UNDERSTAND MEDICATION REGIMEN AND CARE RELATED TO HISHER DISEASEWILL BE DISCHARGE WHEN MAXIMUM FUNCTIONAL POTENTIAL REACHED
Patient Name Med Record
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XPatient Signature if required optional if itinerary is used
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- OASIS_C_SOC
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- PT ID PERFORMED VIA NAME DOB FACE RECOGNITION AND ADDRESS BEFORE SERVICE PROVIDED Off
- TIME IN
- TIME OUT
- Agency Name SALUD HOME CARE INC
- Phone 305-555-5555
- Employees NameTitle Completing the OASIS
- who has signed the plan of care
- Physician name
- Address 1
- Address 2
- Phone Number
- Address 1_2
- Address 2_2
- Patient Phone
- Reason
- Name
- Other Physician if any
- Phone_2
- Address 1_3
- Address 2_3
- Phone Number_2
- REFERRAL SOURCE if not from Primary Physician
- undefined_6
- Phone_3
- Fax
- Evacuation Form needed Emergency Reg 1
- Evacuation Form needed Emergency Reg 2
- EMERGENCY CONTACT
- Address
- Comments 1
- Comments 2
- Phone_4
- Relationship
- OTHER
- Comment 1
- Comment 2
- 11 Other specify
- a
- b
- 7 Other specify
- c
- d
- e
- f
- a_2
- b_2
- d_2
- e_2
- f_2
- a_3
- b_3
- d_3
- Comment if needed 1
- Comment if needed 2
- a_4
- a_5
- a_6
- Date 23
- undefined_7
- undefined_8
- b_4
- b_5
- b_6
- Date_2
- undefined_9
- undefined_10
- Date_3
- undefined_11
- undefined_12
- d_4
- d_5
- d_6
- Date_4
- undefined_13
- undefined_14
- Date_5
- undefined_15
- undefined_16
- Date_6
- undefined_17
- undefined_18
- 12 1
- 12 2
- Date_7
- undefined_19
- undefined_20
- Date_8
- undefined_21
- undefined_22
- MAIN REASON FOR HOME HEALTH CARE 1
- MAIN REASON FOR HOME HEALTH CARE 2
- Fractures site
- Surgeries site
- Cancer site
- Open Wound site
- Decubitus site
- Other specify
- Other
- Pending or Needed
- Yes Number of times
- Reason s Dates
- MobilityAmbulatory devices used
- Other specify_2
- undefined_23
- Comments if needed 1
- Comments if needed 2
- Comments if needed 3
- Comments if needed 4
- undefined_24
- Name_2
- Phone number if different from patient
- Relationshiphealth statusability to help 2
- Any paid help explain
- Specify 1
- Specify 2
- Specify 3
- Any ears surgeryprocedure
- Date_9
- Otherspecify 1
- Otherspecify 2
- Other agencies involved in care 1
- Other agencies involved in care 2
- 1
- 2
- Other_2
- Infections
- Cataract surgery Site
- Date_10
- Other eyes surgery Site
- Date_11
- explain 1
- explain 2
- Any nose surgery
- Date_12
- Other specify_3
- 1_2
- 2_2
- MassesTumors site
- Lesions explain
- Any surgeryprocedure
- Other specify 1
- Other specify 2
- Other specify 3
- Date_13
- Other specify_4
- No Problem
- Medication
- Other_3
- Pain control treatmentmeds Side effect mark
- Other_4
- Is there a regular pattern to the pain explain
- Other_5
- Comment
- What was the outcome
- Type II OnsetExacerbation date
- DietOral control specify
- INSULIN dosage frequency scale explain
- 1_3
- 2_3
- Since
- Other_6
- A1c
- BS
- mgdL DateTime
- Blood sugar ranges
- site 1Location site
- site 2Location site
- site 3Location site
- Frequency
- Other_7
- site 1New Onset Exacerbation
- site 2New Onset Exacerbation
- site 3New Onset Exacerbation
- Able to use Glucometer
- site 1Present level 010
- site 2Present level 010
- site 3Present level 010
- Diabetes Management Problems explain 1
- Diabetes Management Problems explain 2
- Other Endocrine problems
- site 1Occasional y Cont Intermittent Frequency Frequently
- site 2Occasional y Cont Intermittent Frequency Frequently
- site 3Occasional y Cont Intermittent Frequency Frequently
- site 1Pain type ach ng burn ng rad ating neura gia etc
- site 2Pain type ach ng burn ng rad ating neura gia etc
- site 3Pain type ach ng burn ng rad ating neura gia etc
- Anemia specify type if known
- site 1Feeling of pain internal external acute chronic
- site 2Feeling of pain internal external acute chronic
- site 3Feeling of pain internal external acute chronic
- site 1Pain is worse morning
- site 2Pain is worse morning
- site 3Pain is worse morning
- Immunodeficiency problems explain
- Other 1
- Other 2
- Other_8
- explain 1_2
- explain 2_2
- explain 3
- explain 4
- Other specify 1_2
- Other specify 2_2
- undefined_25
- undefined_26
- undefined_27
- undefined_28
- undefined_29
- undefined_30
- undefined_31
- undefined_32
- undefined_33
- undefined_34
- undefined_35
- undefined_36
- M1310 Pressure Ulcer Length Longest length headtotoe
- undefined_37
- cm
- greatest width perpendicular to the length
- M1314 Pressure Ulcer Depth Depth of the same pressure ulcer from
- cm_2
- visible surface to the deepest area
- undefined_38
- cm_3
- 1_4
- 2_4
- 3_2
- Other_9
- 4_2
- Caregiver name
- Other_10
- cant integument findings
- Observation
- Observation_2
- Caregiver name_2
- Other_11
- Wound cleaned with specify
- Wound irrigated with specify
- 1 Size
- cm width
- Wound packed with specify
- Location
- Other_12
- Wound dressingcover applied specify
- 2 Size
- cm width_2
- Comments 1_2
- Comments 2_2
- Location_2
- Other_13
- Sizecm LengthxWidthxDepth
- Sizecm LengthxWidthxDepth_2
- Diagram 4Sizecm LengthxWidthxDepth
- Tunneling Undermining cm
- Tunneling Undermining cm_2
- Diagram 4Tunneling Undermining cm
- Stage IIIIIIIV pressure uIcers only
- Diagram 4Stage IIIIIIIV pressure uIcers only
- Odor Fool normal etc
- Diagram 4Odor Fool normal etc
- Edema pedal sacral p tting etc
- Diagram 4Edema pedal sacral p tting etc
- Appearance of the Wound Bed
- Diagram 4Appearance of the Wound Bed
- Treatment Ordered
- Diagram 4Treatment Ordered
- Other_14
- Other_15
- Other_16
- Other_17
- Yes 1
- Yes 2
- Yes 3
- Height
- Weight
- Radiating to
- GainLoss
- lb X
- Frequencyduration
- Sittinglying R
- L
- Standing R
- L_2
- Medication_2
- Temperature
- Other_18
- Apical
- Brachial
- Radial
- Carotid
- Dependent
- Pitting 1234
- Respirations
- Site
- Cramps site
- Disease Management Problems explain
- Right Upper
- Right
- Right Lower
- 1_5
- 2_6
- 3_3
- Left
- Left Upper
- Left Lower
- Pacemaker Date
- Last date checked
- SOB on minimal effortwalk
- Type
- fy
- Other Prob 1
- Other Prob 2
- O2
- Trach sizetype
- CaregiverfamilyOther
- Yes explain 1
- Yes explain 2
- Other_19
- Comments 1_3
- Comments 2_3
- Increase fluids
- Restrict fluids
- Frequency_2
- Amount
- Yes describe 1
- Yes describe 2
- Frequency_3
- Other 1_2
- Other 2_2
- Nocturia x
- Bowel Off
- undefined_52
- Diapersother
- Other_20
- No
- 2TOTAL
- Urinary Catheter Type
- Last changed on
- Foley inserted date
- with
- Inflated balloon with
- Irrigation solution Type specify
- Amount_2
- mL Frequency
- Returns
- No_2
- 1_6
- 2_7
- Describe at risk intervention and plan 1
- Describe at risk intervention and plan 2
- Describe at risk intervention and plan 3
- DischargeDrainage describe
- Lesions
- Blisters
- Masses
- Cysts
- Wart
- Other specify_5
- Surgical alteration
- Prostate problem BPH TURP Date
- undefined_53
- undefined_54
- Selftesticular exam Frequency
- Hysterectomy Date
- undefined_55
- undefined_56
- Date last PAP
- undefined_57
- undefined_58
- Results
- Breast selfexam frequency
- Mastectomy R L Date
- undefined_59
- undefined_60
- Other specify_6
- Last BM
- Diarrhea Frequency
- Bowel regimeprogram
- Incontinence Off
- Urinary Off
- Diapersother_2
- Other_21
- te describe skin around stoma
- Ileostomycolostomy s 2
- Ileostomycolostomy s 3
- Ileostomycolostomy s 4
- Ileostomycolostomy s 5
- Headache Location
- Frequency_4
- Other_22
- Migraine Frequency
- Site_2
- Weakness UE LE Location
- Other specify_7
- Site_3
- IV
- Pump typespecify
- Hand grips Equal Unequal specify
- Feedings Type amtrate
- Strong Weak specify
- Psychotropic drug use specify
- Flush Protocol amtspecify
- DoseFrequency
- Other_23
- Other specify 1_3
- Other specify 2_3
- DressingSite care specify 1
- DressingSite care specify 2
- Interventions instructionsComments 1
- Interventions instructionsComments 2
- Following Un
- versalStandard precautions
- NA
- No Problem_2
- Pain Frequency
- Abdominal girth
- Bowel sounds active absent hypo hyperactive x
- 3 Forgetful Off
- 4 Depressed Off
- 6 Lethargic Off
- 5 Disoriented Off
- 7 Agitated Off
- 2 Comatose
- 8 Other Off
- Forgetful at times Off
- Irritable Off
- Anxious Off
- Alert Off
- Describe 1
- Describe 2
- undefined_61
- Needs interpreter
- Comments 1_4
- Comments 2_4
- Higher Educational Level
- Fracture location
- Swollen painful joints specify
- Explain
- Contractures Joint
- Spiritual resource
- Location_3
- Phone No
- Atrophy
- Other_27
- Explain 1
- Explain 2
- Decreased ROM
- Paresthesia
- Weakness
- Other_28
- Inappropriate followthrough in past
- Amputation BKAKUE RL specify 1
- Amputation BKAKUE RL specify 3
- Amputation BKAKUE RL specify 4
- Treatment
- Treatment_2
- Other specify 1_4
- Other specify 2_4
- History of Falls past 3 months 12 falls M1032
- V s on Status Poor w or w o glasses M1200
- Vision Status Poor Legally blind M1200
- Gait and Balance Balance problem while standing
- Gait and Ba ance Balance problem while walking
- Gait and Balance Decreased muscular coordination
- Pred spos ng D seases 12 present
- Predisposing D seases 3 or more present
- Equipment Issues Oxygen tubing
- 1Row1
- PlanComments 1
- PlanComments 2
- Comment_2
- undefined_62
- b Ambulation
- c Transfer
- DOther specify
- 7Independent in home 1
- 7Independent in home 2
- Other 1_3
- Other 2_3
- Typebrand
- Size
- Gauge
- Length
- Insertion site
- Insertion date
- Flush solution
- Frequency_5
- Injection cap change frequency
- Dressing change frequency
- Other_29
- Siteskin condition
- External catheter length
- OtherComment
- fluid overload Other
- Circumference of arm
- Huber gaugelength
- Yes date
- Last flushed date
- Siteskin condition_2
- Infusion solution typevolumerate
- Dressing
- OtherComment 1
- OtherComment 2
- Drug Name
- Dose
- Route
- Frequency_6
- Duration of therapy
- Drug Name_2
- Dose_2
- Route_2
- Frequency_7
- Duration of therapy_2
- CommentPlan 1
- CommentPlan 2
- Pump type specify
- Other_30
- Lab draws
- Infusion care provided during visit 1
- Infusion care provided during visit 2
- Infusion care provided during visit 3
- Antibiotic therapy
- 1_7
- 2_8
- Other_31
- Removing line date if know
- BraceOrthotics specify 1
- BraceOrthotics specify 2
- BraceOrthotics specify 3
- Needs specify 1
- Needs specify 2
- Oxygen HME Co
- Prosthesis RUE RLE LUELLEOther
- HME Rep
- Grab bars BathroomOther
- Hospital bed Semielec Crank Spec
- Other_32
- NA_2
- Phone_5
- n care
- PlanComments
- N
- Other_33
- undefined_63
- Physical Therapy Total visits
- Speech Therapy Total visits
- visits
- Other Therapy Total visits
- Patient is not assessed to be at risk for falls
- No pain identified
- Patient has no pressure ulcers with need for moist wound healing
- O
- Noncompliance with drug orders
- Expected Outcome
- Patient unable to perform own Wound Care due
- Pat
- to
- Abd Pads Off
- Underpads size
- undefined_68
- Special mattress overlay
- Angiocatheter size
- Ostomy pouch brand size
- Pressure relieving device
- Ostomy wafer brand size
- undefined_69
- SYRINGES
- Batteries size
- Skin protectant
- Glucometer
- Hydrocolloids
- undefined_70
- FOLEYCATH SUPPLIES
- Syringes size
- size
- Oxygen concentrator
- Feeding tube
- Ointment
- Acetic acid
- Other 1_4
- Other 2_4
- Other 3
- Tens unit
- KLING 4
- Other 1_5
- Other 2_5
- Other 3_2
- PatientCG educationteaching this visit for
- MEDICATION Off
- DISEASE PROCESS COMPLICATIONS Off
- undefined_71
- SS OF Off
- ILEAL CONDUITOSTOMY Off
- DIET FLUIDS Off
- undefined_72
- undefined_73
- SKINFOOT CARE Off
- INFECTION CONTROL Off
- OTHER INSTRUCTIONS GIVEN
- Caregiver present during the visit
- NEEDS FURTHER TEACHING Off
- No_3
- Skilled Observation Assessment
- ent Educat
- Wound Care Dress
- Diabetic Observation Care
- Correct handwashing technique followed SG 1
- Correct handwashing technique followed SG 2
- Correct handwashing technique followed SG 3
- Correct handwashing technique followed SG 4
- 21 Included as reference only your Professional Staff must reviewupdatepersonalizedapprove the orders
- SN ORDERS FREQUENCYDURATION
- S COMPLICATIONS
- TH GLUCOMETER OR
- ON
- TEACH GLUCOMETER OR
- NSERTION
- TH
- INST DRESSING CHANGES
- MONITOR STATUS OF WOUND OR DECUBITUS place
- ADMINISTER PRESCRIBED INJECTABLE
- USING
- TH_2
- TH_3
- AND APPLY
- CLEANSE WOUND WITH
- NSE WITH
- AND APPLY_2
- OTHER_2
- DE ORDERS FREQUENCYDURATION
- PT ORDERS FREQUENCYDURATION
- OT ORDERS FREQUENCYDURATION
- ST ORDERS FREQUENCYDURATION
- MSW ORDERS FREQUENCYDURATION
- Included as reference only your Professional Staff must reviewupdatepersonalizeapprove the goals 22
- MRMS
- PROGRAM WITHIN
- CORRECT BODY MECHANICS WITHIN
- COMMUNICATIONS SYSTEMS WITHIN
- undefined_75
- undefined_76
- Date_14
- QA Date Reviewed
- undefined_77
- undefined_78
- Data Entry Date Locked
- undefined_79
- undefined_80
- Date Submitted
- undefined_81
- undefined_82
- SOCD
- SOCM
- SOCY
- SOCM1
- SOCD1
- SOCY1
- Check Box2 Off
- Check Box3 Off
- Check Box4 Off
- TOM
- TOD
- TOY
- FDM
- FDD
- FDY
- Prov 1071523
- BrID
- Check Box9 Yes
- BrIDno
- Check Box11 Off
- DLCM
- DLCD
- DLCY
- LVM
- LVD
- LVY
- DNR1 Off
- Check Box19 Off
- STFL
- PZC
- MCN
- NOMC Off
- SSN1
- SSN2
- SSN3
- SSUK Off
- MAN
- MAUK Off
- DOBM
- DOBD
- DOBY
- SEX Off
- MR
- First
- MI
- Last
- Suffix
- RACE2 Off
- RACE3 Off
- RACE4 Off
- RACE5 Off
- RACE1 Off
- RACE6 Off
- PS3 Off
- PS0 Off
- PS1 Off
- PS4 Off
- PS5 Off
- PS6 Off
- PS7 Off
- PS8 Off
- PS9 Off
- PS10 Off
- PS11 Off
- PS2 Off
- PSUK Off
- Ecode
- COMP Off
- DACM
- DACD
- DACY
- REA Off
- DM
- DD
- DY
- RDM
- RDD
- RDY
- REFDM
- REFDD
- REFDY
- EPT Off
- 14D2 Off
- 14D3 Off
- 14D4 Off
- 14D5 Off
- 14D6 Off
- 14D7 Off
- 14D8 Off
- Check Box39 Off
- icd9c
- icd9a
- icd9b
- icd9d
- icd9e
- icd9f
- Check Box5 Off
- Check Box7 Off
- icd9b2
- icd9c2
- icd9d2
- C_2
- icd9e2
- icd9f2
- icd9a2
- icd9b3
- icd9c3
- C_3
- icd9a3
- icd9d3
- 1005d
- 1005m
- 1005y
- 1018-2 Off
- 1018-1 Off
- 1018-4 Off
- 1018-5 Off
- 1018-6 Off
- 1018-7 Off
- 1018-NA Off
- 1018-UK Off
- 1018-3 Off
- 1012-na Off
- 1012-uk Off
- Radio Button11 Off
- v1020b
- C_5
- e_5
- f_5
- C_6
- e_6
- f_6
- c_4
- e_4
- f_4
- v1020c
- v1020d
- v1020e
- v1020f
- v1020a
- e1020b
- e1020c
- e1020d
- e1020e
- e1020f
- e1020a
- ev1020b
- ev1020c
- ev1020d
- ev1020e
- ev1020f
- ev1020a
- sp12-1
- sp12-2
- Radio Button12 Off
- Radio Button13 Off
- rad0 Off
- rae0 Off
- rdf0 Off
- phhp Off
- phrp1 Off
- phot1 Off
- phoa1 Off
- phfc1 Off
- phca1 Off
- phin1 Off
- phga1 Off
- phif1 Off
- phsg1 Off
- phwd1 Off
- phdc1 Off
- phgn1 Off
- rddmi Off
- imin Off
- inh1n1 Off
- fwpn Off
- fwtn Off
- fwot Off
- phdm1 Off
- PHNY Off
- phcd1 Off
- 10304 Off
- 10301 Off
- 10302 Off
- 10303 Off
- 10327 Off
- M1034 Off
- HBR1 Off
- HBR2 Off
- HBR3 Off
- HBR4 Off
- HBR5 Off
- HBR6 Off
- HBR7 Off
- HBR8 Off
- HBR9 Off
- HBR11 Off
- HBR12 Off
- HBR10 Off
- HBR13 Off
- SOBFT
- 10321 Off
- 10322 Off
- 10333 Off
- 10324 Off
- 10325 Off
- 10336 Off
- M11001 Off
- M1100b Off
- M1100c Off
- Relationshiphealth statusability to help 1
- 10361 Off
- 10362 Off
- 10363 Off
- 10364 Off
- 10365 Off
- 10366 Off
- 1210d Off
- 1210an Off
- 1210hea Off
- 1210OTH Off
- 1210TIN Off
- 1210NP Off
- 12102 Off
- 12101 Off
- 1210uk Off
- 1210h Off
- 1210v Off
- 1200CAT Off
- 1200OTH Off
- 1200JA Off
- 1200CATRL Off
- 1200OTHER Off
- 1200PT Off
- 1200GLAU Off
- 1200NOP Off
- NOSECON Off
- NOSEEP Off
- NOSELS Off
- NOSESINP Off
- NOSEASG Off
- NOSEOTHSP Off
- NOSENP Off
- THROATDY Off
- TROATL Off
- THROATOTH Off
- 1200BV Off
- 1200LB Off
- THROATHO Off
- THOATSO Off
- THROATNP Off
- 1200GL Off
- 1200CO Off
- 1200PR Off
- 1200IN Off
- M1200 Off
- M1220 Off
- M1230 Off
- MOUTHMas Off
- MOUTHGI Off
- MOUTHULC Off
- MOUTHTOO Off
- MOUTHANY Off
- MOUTHOTH Off
- MOUTHNP Off
- M1240 Off
- M1242 Off
- MOUTHDE Off
- MOUTHUP Off
- MOUTHLO Off
- MOUTHPAR Off
- COPYN Off
- MKMEDP Off
- CPCYN Off
- DPRYN Off
- ICPYN Off
- TURGGP Off
- BESTPAINSC2
- WORSES2
- BESTPAINSC
- WORSESC
- BESTPAINSC3
- WORSESC3
- FACESOBS Off
- SCALE010 Off
- WPSL Off
- WPMA Off
- WPMV Off
- WPAMB Off
- WPIMM Off
- WPTR Off
- WPOTH Off
- WPNP Off
- NVIM Off
- WRP4 Off
- WRP5 Off
- WRP6 Off
- WRP7 Off
- WRP8 Off
- WRP9 Off
- WRPOTH Off
- TKMEDNV Off
- TKMEDLDD Off
- TKMEDD Off
- TKMED23 Off
- TKMEDLT3 Off
- PCTSL Off
- PTXSEN Off
- PTXSEV Off
- PTXSECF Off
- PRDOCC Off
- PTXSEOTH Off
- PRDCONT Off
- WRP1 Off
- WRP2 Off
- WRP3 Off
- PRDINT Off
- PRDFRQ Off
- PHYNOTPT Off
- PHYNOTSTF Off
- NVIG Off
- NVIC Off
- NVIAF Off
- DMIJUV Off
- DMTPII Off
- INSDGFQ Off
- DMODIET Off
- ADMOTH Off
- symphyg Off
- sympfat Off
- symhypog Off
- endopcgr Off
- endopostpra Off
- endorand Off
- endolab Off
- bsrange Off
- bsranptcg Off
- endomonsf Off
- endomoncg Off
- endomonsn Off
- endomonoth Off
- dmNapb Off
- othendopb Off
- enlthyr Off
- intoheatcol Off
- endonp Off
- HEMAANE Off
- HEMABLEED Off
- HEMAHEMO Off
- HEMAINMO Off
- HEMAOTH Off
- HEMANP Off
- SKINITCH Off
- SKINRASH Off
- SKINDRY Off
- SKINSCL Off
- SKINRED Off
- SKINBRU Off
- SKINECCH Off
- SKINPALL Off
- SKINJAU Off
- ADMSELF Off
- ADMSCGF Off
- ADMNURS Off
- SKINNP Off
- m1300 Off
- M1302 Off
- M1306 Off
- M1320 Off
- M1322 Off
- M1324 Off
- M1330 Off
- M1332 Off
- M1334 Off
- M1340 Off
- M1342 Off
- M1350 Off
- WCPYN Off
- IPDMYN Off
- APHYN Off
- SDRBY Off
- SDRSN Off
- SDRCG Off
- SDRPT Off
- SDROTH Off
- TECST Off
- TECCL Off
- WDCLW Off
- WDIRRW Off
- WDPKW Off
- WDDREW Off
- DBFEXD Off
- DBFEX2D Off
- DBFEXEOD Off
- DFEX2WK Off
- DBNFEXWK Off
- DFEXOTH Off
- PDPPRL Off
- PDPARL Off
- LSWRL Off
- endobm Off
- endotv Off
- fbs Off
- LSCDRL Off
- ASCCFR Off
- ASCCFL Off
- Right for
- ASCCFLF
- TRINR Off
- BURRL Off
- LEGHP Off
- LEGHAB Off
- DBFEXRN Off
- DFEXCG Off
- DBFEXPT Off
- DBFEXOT Off
- EXSER Off
- EXSERG Off
- EXSANG Off
- EXSER2 Off
- EXSERG2 Off
- EXSANG2 Off
- SHOV Off
- SHAPRD Off
- SHAPOTH Off
- SHOV2 Off
- SHAPRD2 Off
- SHAPOTH2 Off
- cm length
- cm length2
- DBFTEXRNPT Off
- EXDYN Off
- EXDYN2 Off
- APHYN2 Off
- APHYN3 Off
- Loc3w
- Loc2w
- Loc1w
- Loc4w
- Typew1
- Typew2
- Typew3
- Typw4
- sizw3
- tunnw3
- surrw1
- stomaw1
- surrw1a
- stomaw1a
- surrw3
- surrw3a
- stomaw3
- stomaw3a
- surrw2
- surrw2a
- stomaw2
- stomaw2a
- surrw4
- surrw4a
- stomaw4
- stomaw4a
- statgew2
- statgew3
- Odorw2
- Odorw3
- Edemaw2
- Edemaw3
- appw2
- appw3
- Treatment Ordered_2
- Treatment Ordered_3
- Group10 Off
- draick2 Off
- driack3 Off
- draick4 Off
- colw11 Off
- colw12 Off
- colw31 Off
- colw32 Off
- colw33 Off
- colw34 Off
- colw21 Off
- colw22 Off
- colw23 Off
- colw24 Off
- colw43 Off
- colw44 Off
- ital1u1 Off
- ital1u2 Off
- fsrrepo Off
- frsact Off
- rwgchpt Off
- rwgchcgf Off
- rwgchnur Off
- pulreg1 Off
- pulirreg1 Off
- fsrrespreg Off
- colw41 Off
- colw42 Off
- bpsitly Off
- bpstand Off
- fsrwgrep Off
- fsrwgact Off
- tempaxil Off
- temptymp Off
- pulseappical Off
- pulseradial Off
- pulsebrach Off
- pulsecarot Off
- pulserest Off
- pulsecheyn Off
- pulseactiv Off
- respirirreg Off
- respideath Off
- respaccess Off
- respiapnea Off
- bsckrack Off
- temporal Off
- temprect Off
- chestprad Off
- colw13 Off
- colw14 Off
- consth2 Off
- consthic2 Off
- consth3 Off
- consthic3 Off
- consth4 Off
- consthic4 Off
- chestpyes Off
- chestpainno Off
- consth1 Off
- consthic1 Off
- cpsubstern Off
- cpviselike Off
- dm5lin
- assocwithsoboe Off
- associawactv Off
- associwsweat Off
- cphowreloth Off
- cphowrelrest Off
- cphowrelmeds Off
- cppalarr Off
- cppalpfast Off
- cppalpslow Off
- cppalpfatig Off
- cpedema Off
- cpedemapedal Off
- cpangina Off
- cppostural Off
- cplocalized Off
- cpedempedrig Off
- cpedemapedallef Off
- cpedemasacral Off
- cpedemadepend Off
- cpedemapitt Off
- cpedemanonpitt Off
- cstcramp Off
- cardstclaud Off
- cardstcapref Off
- cstcaprefless Off
- castcaprefgreat Off
- csthsreg Off
- csthsirreg Off
- csthsmurmur Off
- cstpacemak Off
- cpstabreassouclear Off
- breassodwheez Off
- bresddimm Off
- chestpaidull Off
- cpache Off
- cpsharp Off
- brsdabset Off
- brsdsobsoboe Off
- brsdsobonmineff Off
- 14001 Off
- 14003 Off
- 14004 Off
- 1400tva Off
- 14002 Off
- 1400car Off
- 14101 Off
- 14102 Off
- 14103 Off
- 14104 Off
- uroops Off
- uropat Off
- urocare Off
- 14000 Off
- urosn Off
- Radio Button2 Off
- 16100 Off
- 16101 Off
- 1400pat Off
- 16concar Off
- 162gm Off
- 16nas Off
- 16npo Off
- 16102 Off
- 161800cal Off
- 16lowfat Off
- 16lowcho Off
- 16incflu Off
- 16restflu Off
- 16exc Off
- 16good Off
- 16fair Off
- 16poor Off
- 16anore Off
- 16nau Off
- 16vom Off
- 16heabur Off
- O2satur
- O2firesaf Off
- O2sn Off
- O2carefamother Off
- O2cough Off
- O2no Off
- O2yes Off
- O2nonprod Off
- O2noc Off
- O2yesc Off
- O2dys Off
- O2rest Off
- O2dADL Off
- O2sliplo Off
- O2nop Off
- O2yesp Off
- 16other Off
- genibur Off
- genihes Off
- genihema Off
- geniolig Off
- geniurg Off
- geninoc Off
- geniincon Off
- geniuri Off
- genidiap Off
- 16lowna Off
- genicyell Off
- genicamber Off
- genicbr0 Off
- genicbt Off
- genicother Off
- genicla Off
- geniclo Off
- genised Off
- geniodno Off
- genifol Off
- geniwitdif Off
- genisup Off
- geniyes Off
- genino Off
- 1620 Off
- 1615 Off
- 1630 Off
- 1630cosn Off
- 1630lBM Off
- 1630diar Off
- 1630rect Off
- 1630hemo Off
- 1630incon Off
- 1630diap Off
- 1630lax Off
- 1630w Off
- 1630d Off
- 1630m Off
- 1630lleost Off
- 1630pat Off
- 1630car Off
- 1630sn Off
- 1630ot Off
- 1630np Off
- 1630follow Off
- genblis Off
- genmass Off
- gencys Off
- genwart Off
- geninf Off
- gensurg Off
- genprost Off
- gensef Off
- genmeno Off
- genhyst Off
- gendisc Off
- geniodyes Off
- gennp Off
- 1630flat Off
- 17001 Off
- 17002 Off
- 17004 Off
- 1700head Off
- 1700perr Off
- 1700up Off
- 1700apha Off
- 1700rec Off
- 1700exp Off
- 1700mot Off
- 1700gro Off
- 1700dom Off
- 1700weak Off
- 1700trem Off
- 1700fine Off
- 1700gross Off
- 1700paral Off
- 1700stu Off
- 1700halluc Off
- 1700psy Off
- 1700oth Off
- 1700np Off
- EFAD TPN Off
- 17003 Off
- EFAD jej Off
- EFAD iv Off
- EFAD pum Off
- EFDA bol Off
- EFDA con Off
- EFA pat Off
- EFDA sn Off
- EFDA car Off
- EFDAoth Off
- EFDAfu Off
- EFDA na Off
- EFDA np Off
- abd pa Off
- ABD dis Off
- ABD hard Off
- ABD soft Off
- ABD asc Off
- ABD ab Off
- ABD oth Off
- ABD bow Off
- ABD other Off
- ABD ten Off
- EFAD Nas Off
- efad gas Off
- EFAD ot Off
- 17101 Off
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- 17104 Off
- 17105 Off
- 17100 Off
- 1720 Off
- gen dis Off
- genbre Off
- genmast Off
- genoth Off
- 1700fin Off
- 1700mig Off
- genles Off
- 1630 other Off
- 1730 Off
- 1745 Off
- 1750 Off
- 17450 Off
- 1730a Off
- 1730b Off
- 17000 Off
- 17401 Off
- 17402 Off
- 17404 Off
- 17405 Off
- 17406 Off
- 17407 Off
- 1 Oriented Off
- msnp Off
- pslb Off
- psni Off
- psd Off
- psnas Off
- lbm Off
- lbps Off
- lbph Off
- lbf Off
- lbs Off
- urw Off
- sceri Off
- 17403 Off
- ps Off
- ABD pn Off
- pslm Off
- psdp Off
- pspl Off
- psrf Off
- psnh Off
- psue Off
- psir Off
- pse Off
- psep Off
- psea Off
- psvep Off
- psin Off
- psph Off
- psab Off
- psfin Off
- msor Off
- msfr Off
- msre Off
- msp Off
- mssw Off
- mscon Off
- msat Off
- msad Off
- mscan Off
- msuns Off
- mstp Off
- mswal Off
- msdec Off
- par Off
- msot Off
- mssh Off
- mswe Off
- mswea Off
- mskp Off
- msother Off
- mshe Off
- mspa Off
- msqua Off
- msoth Off
- msnop Off
- psina Off
- pssi Off
- psnap Off
- psinap Off
- psan Off
- psfat Off
- pswit Off
- psdif Off
- psdis Off
- psdep Off
- psanx Off
- psnp Off
- psade Off
- psdisc Off
- mscom Off
- msamp Off
- FL2 Off
- FL3 Off
- FL7 Off
- FL8 Off
- FL9 Off
- FLA-d Off
- FLb Off
- FLg Off
- FLart Off
- FLdiz Off
- FLhead Off
- FLins Off
- FLanx Off
- FLsob Off
- FLpoor Off
- FLprod Off
- FLheart Off
- FLp Off
- FLu Off
- FLv Off
- FLed Off
- FLc Off
- FLf Off
- FL1l Off
- FL1b Off
- FL1d Off
- FL1p Off
- FL1li Off
- FL1lr Off
- FL1lc Off
- FL1f Off
- FL1n Off
- FL4 Off
- FL6 Off
- FL5 Off
- adl o Off
- adl 1 Off
- adl 2 Off
- adl 3 Off
- 1810 0 Off
- 1810 1 Off
- 18102 Off
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- 19100 Off
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- FL1 Off
- 1910sg Off
- 1910sgp Off
- 1910sgd Off
- 1111910sgp Off
- 1910sgo Off
- 18302 Off
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- 1910sgpat Off
- 18901 Off
- 18902 Off
- 18903 Off
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- adlr Off
- adlna Off
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- adlm Off
- adlp Off
- adlot Off
- adlst Off
- 18303 Off
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- 1845 Off
- 1880 Off
- adl Off
- 1850 Off
- 1860 Off
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- 19108 Off
- 19109 Off
- 1910aw Off
- 1910bw Off
- 1910cnr Off
- 1910do Off
- alleasp Off
- alleggs Off
- alleib Off
- allesulf Off
- allead Off
- alledm Off
- allelod Off
- allepol Off
- alledust Off
- alleother Off
- 20000 Off
- 2000na Off
- 14D1 Off
- 20001 Off
- 20002 Off
- 2010 Off
- 2002 Off
- 2040a Off
- 2040b Off
- 2020 Off
- 2030 Off
- infpat Off
- picccir Off
- ivadacc Off
- int Off
- fo Off
- fa Off
- ule Off
- infiv Off
- perip Off
- mc Off
- gros Off
- tun Off
- nt Off
- ld Off
- lt Off
- cl Off
- pat Off
- rn Off
- cg Off
- ivocc Off
- ivflu Off
- res Off
- red Off
- allerno Off
- iv-i Off
- adp Off
- adc Off
- adrn Off
- adoth Off
- pia Off
- athe Off
- eiv Off
- biood Off
- mva Off
- pn Off
- infna Off
- infcare Off
- rldna Off
- 2100a Off
- 2100b Off
- 2100c Off
- 2100d Off
- 2100e Off
- 2100f Off
- 2100g Off
- 2110 Off
- asheb Off
- ashmet Off
- asehmop Off
- asprost Off
- asebed Off
- aseshow Off
- asescoot Off
- asehoist Off
- asegrab Off
- asehosp Off
- aselif Off
- asewhee Off
- aseoth Off
- aseneed Off
- aseoxy Off
- asefire Off
- aseph Off
- aseorg Off
- asena Off
- smlasa Off
- pump Off
- smcou Off
- smght Off
- smpup Off
- smrp Off
- smwd Off
- smal Off
- smpco Off
- smpfi Off
- smsa Off
- smpic Off
- smsp Off
- smtsc Off
- smsd Off
- smgip Off
- smgup Off
- smst Off
- smcc Off
- smpes Off
- smep Off
- smms Off
- smcp Off
- smcpat Off
- smcht Off
- smcfsh Off
- smpsbp Off
- smoth Off
- oxgava Off
- oxknosw Off
- prr Off
- shan Off
- adi Off
- epci Off
- apn Off
- cih Off
- pmi Off
- sphic Off
- acihsf Off
- dcdmi Off
- dnr Off
- sac Off
- opnc Off
- msr Off
- hsg Off
- asii Off
- gp Off
- fpp Off
- other Off
- pttv Off
- ottv Off
- sttv Off
- ottvist Off
- oxu Off
- oxupe Off
- oufsp Off
- sh Off
- ih Off
- hd Off
- fab Off
- ug Off
- ir Off
- us Off
- nta Off
- pp Off
- mss Off
- ep Off
- ev Off
- sb Off
- adce Off
- sf Off
- ppf Off
- rma Off
- hsd Off
- ppnf Off
- dfc Off
- fpi Off
- dim Off
- imm Off
- ipp Off
- put Off
- cp Off
- ph Off
- sn Off
- ot Off
- st Off
- aid Off
- oth Off
- mfc Off
- nch Off
- oo Off
- mmc Off
- idt Off
- sse Off
- sdi Off
- ncwdo Off
- ddt Off
- eo Off
- no so-cg Off
- nancg Off
- salin Off
- 2x2 Off
- 4x4 Off
- abd Off
- telf Off
- tap Off
- wg Off
- glov Off
- ns Off
- hyd Off
- ks Off
- td Off
- oint Off
- cs Off
- ther Off
- rb Off
- ic Off
- ivsk Off
- ivp Off
- ivt Off
- as Off
- asi Off
- per Off
- et Off
- cid Off
- ip Off
- ss Off
- duo Off
- bs Off
- abs Off
- m2x11 Off
- mt2 Off
- s4x4 Off
- ng Off
- und Off
- ec Off
- ub Off
- op Off
- ow Off
- sat Off
- fol Off
- ls Off
- sc Off
- tc Off
- aa Off
- otth Off
- app Off
- chem Off
- cta Off
- dcfg Off
- hyt Off
- it Off
- syr Off
- glu Off
- es Off
- ft Off
- srk Off
- strk Off
- sstri Off
- is Off
- stst Off
- ta Off
- vg Off
- kl Off
- sr Off
- bath Off
- can Off
- com Off
- smo Off
- prd Off
- egg Off
- hb Off
- hl Off
- efp Off
- neb Off
- oc Off
- pup Off
- pui Off
- or Off
- inj Off
- ivinf Off
- inh Off
- pcbp Off
- fcc Off
- pe Off
- wcd Off
- pai Off
- doc Off
- soa Off
- injr Off
- pt Off
- sup Off
- atu Off
- qc Off
- sd Off
- cht Off
- mep Off
- ncfa Off
- dpd Off
- wdc Off
- dmc Off
- iad Off
- gc Off
- nmd Off
- trc Off
- oca Off
- fc Off
- pfv Off
- oup Off
- uhm Off
- pmh Off
- eim Off
- e911 Off
- puitc Off
- cpdv Off
- dpdp Off
- rp Off
- ko Off
- ipai Off
- iop Off
- iudp Off
- dc Off
- ds Off
- spe Off
- sfcp Off
- ispm Off
- npp Off
- fi Off
- issi Off
- cqm Off
- idc Off
- msw Off
- iicm Off
- ign Off
- ret Off
- mrw Off
- pcd Off
- dccw Off
- ort Off
- epum Off
- meac Off
- pebp Off
- iap Off
- iiph Off
- iccs Off
- ipc Off
- icdb Off
- ipm Off
- ipap Off
- eiad Off
- ipaot Off
- odit Off
- mepc Off
- ttdp Off
- scwc Off
- mr Off
- dn Off
- cef Off
- pcm Off
- si Off
- spi Off
- eplan Off
- oa Off
- nmbs Off
- tg Off
- idp Off
- ipd Off
- icid Off
- igp Off
- ief Off
- ida Off
- nss Off
- api Off
- aps Off
- pst Off
- sib Off
- sdp Off
- ippph Off
- aperi Off
- pf Off
- ap Off
- apv Off
- pa Off
- ans Off
- imb Off
- imt Off
- ewl Off
- acb Off
- mlc Off
- eob Off
- afs Off
- paa Off
- rt Off
- das Off
- got Off
- lsm Off
- dpc Off
- ils Off
- mpb Off
- iao Off
- ihc Off
- mfs Off
- ipcp Off
- tae Off
- iua Off
- tsb Off
- pc Off
- hc Off
- sp Off
- mdc Off
- oh Off
- tpr Off
- ad Off
- awa Off
- psm Off
- gs Off
- wc Off
- lhk Off
- awpc Off
- errand Off
- nlb Off
- fnc Off
- pric Off
- rsf Off
- src Off
- ebc Off
- ppt Off
- gtwa Off
- ebp Off
- eem Off
- nme Off
- nsf Off
- bmt Off
- thm Off
- tt Off
- ism Off
- ephs Off
- irle Off
- isc Off
- atp Off
- mre Off
- te Off
- pas Off
- sfe Off
- pom Off
- sad Off
- isp Off
- fsm Off
- idy Off
- vdt Off
- ar Off
- noc Off
- ldt Off
- mfa Off
- crm Off
- crp Off
- lrp Off
- mrms Off
- sps Off
- acmr Off
- hwi Off
- hdic Off
- psn Off
- dsdc Off
- usb Off
- dcw Off
- saic Off
- dptw Off
- rsm Off
- kss Off
- uhc Off
- hpa Off
- ipi Off
- grp Off
- ftcm Off
- wac Off
- ria Off
- paf Off
- pafi Off
- pwe Off
- ptc Off
- ges Off
- otp Off
- pwdf Off
- pdaf Off
- pdi Off
- pdis Off
- phas Off
- pep Off
- 12100 Off
- allepen Off
- Patient is not diabetic or is bilateral amputee
- mswref Off
- genitonoprob Off
- Urostomy describe skin around stoma Off
- nutrinoprob Off
- O2prod Off
- woraft Off
- woreve Off
- wormor Off
- worsleep Off
- prodsputcol
- fname Off
- Rehabdc1 Off
- mswgwk1
- stgwk2
- stgwk1
- stgwk3
- rhpoor Off
- Clear Form
- E-mail Form
ALLERGIES MEDICATIONS(M2040) Prior Medication Management Indicate the patients usualability with managing oral and injectable medications prior to this currentillness exacerbation or injury Check only one box in each row
None known NKA AspirinSulfaPollens and mold spores
EggsPenicillin
Insect bitesDairyMilk products
Functional Area Independent NeededSome Help Dependent Not
Applicable
a Oralmedications 0 1 2 na
b Injectablemedications 0 1 2 na
Other
MEDICATIONS
(M2000) Drug Regimen Review Does a complete drug regimen reviewindicate potential clinically significant medication issues eg drugreactions ineffective drug therapy side effects drug interactionsduplicate therapy omissions dosage errors or noncompliance
0 - Not assessedreviewed [Go to M2010]
1 - No problems found during review [Go to M2010]
2 - Problems found during reviewNA - Patient is not taking any medications [Go to M2040]
INFUSION IV THERAPYNA
(M2002) Medication Follow-up Was a physician or the physician-designee contacted within one calendar day to resolve clinicallysignificant medication issues including reconciliation
Peripheral line Central line
Typebrand
0 - No
Size
1 -Yes
Non-tunneledGroshong Non-Groshong TunneledInsertion site Insertion date
(M2010) PatientCaregiver High Risk Drug Education Has the patientcaregiver received instruction on special precautions for all high-riskmedications (such as hypoglycemics anticoagulants etc) and how andwhen to report problems that may occur
Lumens DoubleSingle TripleFlush solution
YesPatent N o
0 - No
Injection cap change frequency
1 -Yes
Dressing change frequency
NA - Patient not taking any high risk drugs OR patientcaregiver fullyknowledgeable about special precautions associated with allhigh-risk medications
Sterile CleanPatient RNPerformed by Caregiver Other
Siteskin condition
(M2020) Management of Oral Medications Patients current ability toprepare and take all oral medications reliably and safely includingadministration of the correct dosage at the appropriate timesintervalsExcludes injectable and IV medications (NOTE This refers to abilitynot compliance or willingness)
External catheter lengthOtherComment
0 - Able to independently take the correct oral medication(s) and
PICC Specific
proper dosage(s) at the correct times
Circumference of arm
1 - Able to take medication(s) at the correct times if
X-ray verificationYes No
(a) individual dosages are prepared in advance by another personOR
IVAD Port Specific
(b) another person develops a drug diary or chart
Reservoir DoubleSingle
2 - Able to take medication(s) at the correct times if given reminders
Huber gaugelength
by another person at the appropriate times
NoAccessed Yes date
3 - Unable to take medication unless administered by another person
EpiduralIntrathecal Access
NA - No oral medications prescribed
Siteskin condition
(M2030) Management of Injectable Medications Patients currentability to prepare and take all prescribed injectable medications reliablyand safely including administration of correct dosage at the appropriatetimesintervals Excludes IV medications
Infusion solution (typevolumerate)DressingOtherComment
0 - Able to independently take the correct medication(s) and properdosage(s) at the correct times
1 - Able to take injectable medication(s) at the correct times if
IV-Infusion Medication(s) administered
(a) individual syringes are prepared in advance by another
Drug Name
person OR
RouteDose
(b) another person develops a drug diary or chart
Frequency Duration of therapy
2 - Able to take medication(s) at the correct times if given remindersby another person based on the frequency of the injection
IV-Infusion Medication(s) administered
3 - Unable to take injectable medication unless administered by
Drug Name
another person
Dose Route
NA - No injectable medications prescribed
Frequency Duration of therapy
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Patient Name Med Record
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Financial ability to pay for medications Yes No
Was MSW referral made Yes
CommentPlan
Infusion IV Therapy order obtained verified
Gauge Length
Frequency
Iodine
Medline catheter
No
- Unsafe Living Environment -Pt demo unsafe behavior or choices - Limited Resources -At risk and lives alone -Pt is CG for another Yes No
Intravenous IV Port Yes No Flush Ordered Yes NoLast flushed date(vascular access device)
IV Therapy complication observed Pain amp irritation Infiltration amp exravasionOcclusionobstruction fluid overload Other
Dust mitesAnimal dander and urine
(SOC)
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INFUSION IV THERAPY (Contd)
Infusion care provided during visitPump (type specify)OtherCaregiverPatient RNAdministered by
Purpose of Intravenous Access
Pain control
Lab drawsInterventions Instructions Comments Problems DetectedAntibiotic therapy
Maintain venous accessChemotherapyParenteral nutrition (TPN)HydrationOther
CARE MANAGEMENT
(M2100) Types and Sources of Assistance Determine the level of caregiver ability and willingness to provide assistance for the following activitiesif assistance is needed (Check only one box in each row)
Caregiver(s)Caregiver(s) Unclear ifNeed TrainingCaregiver(s) AssistanceNo Assistance Not Likely toCurrently Supportive Caregiver(s) Needed ButType of Assistance Needed in This Provide ProvideServices to Will Provide No Caregiver(s)Area Assistance AssistanceAssistance Provide Available
Assistance
a ADL Assistance (egtransferambulation bathingdressing toileting eatingfeeding)
0 1 2 3 4 5
b IADL Assistance (egmeals housekeepinglaundry telephone shoppingfinances)
0 1 2 3 4 5
c Medication Administration(eg oral inhaled orinjectable)
0 1 2 3 4 5
d Medical ProceduresTreatments (eg changingwound dressing)
0 1 2 3 4 5
e Management of Equipment(includes oxygen IVinfusionequipment enteralparenteralnutrition ventilator therapyequipment or supplies)
0 1 2 3 4 5
f Supervision and Safety(eg due to cognitiveimpairment)
0 1 2 3 4 5
g Advocacy or Facilitation ofpatients participation inappropriate medical care(includes transportation to orfrom appointments)
0 1 2 3 4 5
(M2110) How Often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)1 - At least daily 4 - Received but less than weekly
5 - No assistance received2 - Three or more times per weekUK - Unknown3 - One to two times per week
APPLIANCES SPECIAL EQUIPMENT HOME MEDICAL EQUIPMENT Co
Needs (specify)BraceOrthotics (specify)
Bedside commodeTransfer equipment BoardLift Oxygen HME Co
Prosthesis RUE RLE LUELLEOther HME Rep
Grab bars BathroomOther
PhoneOrganizations providing Home Medical Equipment (HME)
Hospital bed Semi-elec Crank SpecLifeline
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Patient Name Med Record
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Ostomy Pliers Shower chair Scooters Hoists
Wheeled Walker Other Phone NA
NA
Removing line date (if know)
Expand intravascular volume
Blood and its derivativesNA
NA
NA
(SOC)
SGFire PreventionSafety Program in place Patient instructed
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SAFETY MEASURES LIVING ARRANGEMENTS SUPPORTIVE ASSISTANCE
Oxygen use NYSigns postedYFollow smoking flammables safety precautions N
Oxygen back-up Knows Instructed how to useAvailable
Oxygen Precautions explained
PlanComments
Safety hazards in the home (check all that apply)NYFire alarmsmoke detector Fire extinguish
Inadequate heating cooling electricity lightingHurricane Disaster Emergency supplieskits
NY
InstructionsInformation Provided Sign Up package (Check all that apply)
Y N
Patient Rights and responsibilities
NYFirst aid boxEmergency Equipment or Supplies
State hotlineABUSE number
NYUnsafe gaselectrical appliances or electrical outlets
Advance directives information
NYInadequate running water plumbing problemsDo not resuscitate (DNR) (if applicable)NUnsafe storage of supplies equipment HME
No telephone available andor unable to use the phonePest problems InsectsrodentsMedications stored safely clearly-easy use check interactions
Service AgreementContractNYOASISHIPAA Privacy Notice ConfidentialityNY
Emergency Plan classification instructionsNYAgency phone numbers addressEmergency planning Exit Plan in place more than one exitClient Information Handbook
Y N
Standard precautions handwashing Infection Control
NYEnough Ventilation
Home safety guidelines
Safe BedsChairs clear pathways
Admission criteria Information for Home visit Services FrequencyY NAble to follow directions in case of Emergency
Diabetes Control other disease management informationNYSlippery Floors Ashtrays (if a smoker)
Fall Prevention Program
NYPlan for power failure emergency lights flashlights etc
THERAPY AND PLAN OF CARE(M2200) Therapy Need in the home health plan of care for the Medicarepayment episode for which this assessment will define a case mixgroup what is the indicated need for therapy visits (total of reasonableand necessary physical occupational and speech-language pathologyvisits combined) (Enter zero [000] if no therapy visits indicated)
) Number of therapy visits indicated (total of physicaloccupational and speech-language pathology combined)
(
NA - Not applicable No case mix group defined by this assessment(M2250) Plan of Care Synopsis (Check only one box in each row) Does the physician-ordered plan of care include the following
PlanIntervention YesNo Not Applicable
a Patient-specific parameters for notifying physician ofchanges in vital signs or other clinical findings 0 1 na
Physician has chosen not to establish patient-specific parameters for this patient Agency will usestandardized clinical guidelines accessible for allcare providers to reference
b Diabetic foot care including monitoring for the presence ofskin lesions on the lower extremities and patientcaregivereducation on proper foot care
0 1 naPatient is not diabetic or is bilateral amputee
c Falls prevention interventions 0 1 na Patient is not assessed to be at risk for falls
d Depression intervention(s) such as medication referral forother treatment or a monitoring plan for current treatment 0 1 na Patient has no diagnosis or symptoms of
depression
e Intervention(s) to monitor and mitigate pain 0 1 na No pain identified
f Intervention(s) to prevent pressure ulcers 0 1 na Patient is not assessed to be at risk for pressureulcers
g Pressure ulcer treatment based on principles of moistwound healing OR order for treatment based on moistwound healing has been requested from physician
0 1 naPatient has no pressure ulcers with need for moistwound healing
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Y
NY
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Patient Name Med Record
HOME ENVIRONMENT SAFETY
NYRelevant medical appliances if applicable ( wheelchair O2 Monitors etc)NYHurricane Shutter Disaster Plan
Medication sheet reconciliatedchecked
Alzheimers Sensory impairments info
Care Plans
Pain Management info Grievance Procedures
Local Resources Guide Mission ownership information
Physical Therapy Total visitsOccupational Therapy Total visits
Speech Therapy Total visitsOther Therapy Total visits
(SOC)
Safety Measures CMS485 (POC)
Cast PrecautionsChange position slowlyCoumadinHeparin PrecautionsDo not lift bend stoopGood handwashing techniqueOxygen PrecautionFire preventionPractice Universal Precautions
15
Safe Ambulation
Respiratory PrecautionsDiabetic PrecautionsWoundDecubitus precautionsAdequate lightingPrevent Cardiac OverloadPrevent Falls and Injuries GI Precautions
Prev Infection ComplicationsSeizure PrecautionsSuicide precautionsSupport due functional limitationTeach coping skillsSafe storagedisposal syringes Cardiac Precautions
GU Precautions
Safe TransfersSAN PrecautionsCatheter CareProvide Emotional SupportEmergency Plan
Maintain Safeclear EnvironmentMaintain Good Skin care
Clear pathways
Other
SG
Correct handwashing technique SG
Check bathroom floorstairs for safety hazardsPsycho-social behavior precautions
SG
SGSG
SG
SG
SG
Other
SG
SG
SG
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PATIENT CARE COORDINATION
CARE PLAN Reviewed with patient involvementOrder obtainedMedication Form completedreviewedupdated No changeMEDICATION RECORD
Ineffective drug therapySignificant drug interactions
Significant side effectsNon-compliance with drug orders Duplicate drug therapy
Other (specify)M S WSNPhysician AidePT OT STCARE COORDINATION
Explain
Yes No
DME SUPPLIES
IV start kit Underpads size BathbenchChemstrips2x2sIV pole
External catheters
Syringes Cane Quad CaneIV tubing
Urinary bagpouch
COTTON TIP APP4x4s
CommodeAlcohol swabs
Ostomy pouch (brand size)
Special mattress overlayABDs
Angiocatheter size
Cotton tipped applicatorsPeroxide Ostomy wafer (brand size)
Pressure relieving device
Wound cleanserExtension tubingsWound gel
Injection caps
Stoma adhesive tape
Eggcrate
Drain sponges Central line dressing
Skin protectant
Hospital bed
GlovesNon-sterile
Side Rails
Infusion pump Hoyer lift
Sterile Batteries size Enteral feeding pump
Hydrocolloids
Enema suppliesSyringes size
Nebulizer
Kerlix size
Feeding tubeNu-gauze
MEFIX 2X11 YD (EA)
Oxygen concentrator
sizetype Suction machine
SalineNSS
FOLEYCATH SUPPLIES
Suture removal kit Ventilator
Tape
Fr catheter kit
Staple removal kit Walker
(tray bag foley)Transparent dressings
Steri strips
Straight catheter
Wheelchair
Ointment
TRIPLE ANTIBIOTIC 30GR
Irrigation tray
Tens unitSalineNSS
OtherAcetic acid
Other
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Patient Name Med Record
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10
14
PATIENTCAREGIVER INSTRUCTIONS-TEACHINGCheck all that appliesPatientcaregiver(CG) independent with
Trach care
N oYesWoundDecubitus care
Yes No
Yes N o
Ostomy care Yes
N oYesDiabetic managementcare
N o
N oYesNoYesInsulin administration N oYes
Oxygen useprecautions
Yes N oGlucometer usecalibration N oYes
Use of home medical equipmentdevices
N oYesNutritional managementDiet
NoCaregiver present during the visit Yes
PatientCG educationteaching this visit for
N oYesPatientCG able to understand instructionsteaching
Does the patientCG have a plan when disease symptoms exacerbate (eg when to call the nurseAgency vs emergency 911) N oYes
Comment(s)
SKILLED CARE PROVIDED THIS VISIT
Medication management Administration Oral Injection IV-Infused Inhaled
Foley care Yes N o
Pain ManagementHome prescribed exercisesActivities of Daily LivingPersonal Care
MEDICATION
DISEASE PROCESS COMPLICATIONSSS OFILEAL CONDUITOSTOMY SKINFOOT CAREDIET FLUIDS INFECTION CONTROL
OTHER INSTRUCTIONS GIVEN
N oYesElimination Incontinence management
NEEDS FURTHER TEACHINGExplain
NA NANANANANA
NANANANANANANA
Yes N oPhysician follow up visitsappointments NA
Expected Outcome
DISCHARGE PLANNING DISCUSSEDEXPLAINED Patient unable to perform own Wound Care dueto
Patient unable to InsulineInjection self administration dueto
No SO or CG ablewilling for wound careInsulin-Injection administration at this time
Telfa
Colostomy Supplies
Thermometer
Texas Cath
Red Box (Biohazard)
Betadine Solution
Abd Pads
Duoderm
Sharp Container
Ace band size
Leg Straps Cath
ALCOHOL PREP PADS
DUODERM CFGHY-TAPE 2INSERTION TRAY 5CC
INSULIN SYRINGE ____ CCSYRINGES
Glucometer
MICROPORE TAPE 2
SOFTWICK 4X4
VASELINE GAUZE 3X9
KLING 4
(SOC)
Medication Management Check all that appliesidentified Potential adverse effectsdrug reactionsSG
Skil led Observation AssessmentINJECTION ROUTE_______ SITE _____ MED GIVEN ______________________ DOSE __________ REACTION _____________________________
Foley ChangeCare Patient Educationteaching Wound Care Dressing Change Prep Admin Insulin
StandardUniversal Precautions Followed Aseptic Tech Used Quality Control of Glucometer Performed Sharps Discarded Inside Sharps Container
ProcedureTx welltolerated by Pt
Diabetic Observation Care
Correct handwashing technique followed SG ManagementEvaluation Patients Care Plan No caregiverfamily availablewilling to help patient with care procedures
SG
Pshycological carebehaviour problems prevention NA
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Orders by discipline (optional) To complete CMS485 (POC)
SN - ORDERS - FREQUENCYDURATION
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Patient Name Med Record
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21
OTHER
General
Psychiatric
F o l e y Care
REPORT ANY ELEVATIONS IN TEMPERATURE TO THE MD
Wound CareDecubitus
IMPROVE THE PTS ABILITY TO PREVENT OR COPE WITH BREATHING DIFFICULTIES
Asthma Respiratory
INST FOR SS EASY FATIGABILITY DYSPNEA PALPITATIONS ANGINA TACHYCARDIAPALLOR DIZZINESS JAUNDICE AND FEVER INST FOR G I DISTURBANCES ASSESS FOR CENTRALNERVOUS SYSTEM SYMPTOMATOLOGY OBTAIN APPROPRIATE LAB TESTS AND REPORT FINDINGS TO MD ADMINISTER PRESCRIBED INJECTABLE _________________ USING ______ TECHNIQUE
Anemia
Included as reference only your Professional Staff must reviewupdatepersonalizedapprove the orders
INSTRUCT IN PREPARATION amp ADMINISTRATION OF INSULIN INSTRUCT ONSET PEAK ampDURATION OF ACTION OF INSULIN INSTRUCT PROPER DISPOSAL OF SYRINGESNEEDLES NURSE TO MONITOR BLOOD SUGAR WITH GLUCOMETER OR ___________ON __________FREQUENCY ampNOTIFY MD OF ALTERED RESULTS TEACH GLUCOMETER OR __________ PROCEDURE amp INTERPRETING RESULTS
InsulinGlucometer
INST DISEASE PROCESS amp COMMON COMPLICATIONS INST PRESCRIBED DIET amp SHOPPING ADVICE INST SSHYPOHYPERGLYCEMIA amp EMERGENCY PROCEDURES INST GOOD SKIN CARE amp GOOD FOOT CARE DAILY CARE OFTEETH INST DIABETIC CHART INST SampA TESTING amp READING RESULTS INSTRUCT TO CARRY ID THAT INCLUDESINFORMATION REGARDING DIABETIC STATUS NAMES amp DOSAGE OF MEDS amp ACTION TO TAKE IF INSULIN REACTION OCCURS INST IMPORTANCE OF GOOD PERSONAL HEALTH HABITS INCLUDING EXERCISE ADEQUATEREST SLEEP REGULAR MED CHECK-UPS (INCLUDING PODIATRIC OPTHAMOLOGIST amp DENTIST)
DiabetesMellitus
INST PACED ACTIVITY PROGRAM
OBSERVE FOR SS OF DECOMPENSATION SUCH AS INCREASING TACHYCARDIA WSUDDEN ONSET SOB ON MINEXERTION ORTHOPNEA EXTREME ANXIETY PROGRESSIVE CYANOSIS GENERALIZED PALLOR AND DIAPHORESISCHF
INSTRUCT PROPER ADMINISTRATION OF OXYGEN THERAPY INSTRUCT OXYGEN PRECAUTIONSINSTRUCT MAINTENANCE OXYGEN EQUIPMENTOxygen
ASSESS FOR CHEST PAIN TYPE LOCATION INTENSITY DURATION amp FREQUENCY IS PAINMANAGEMENT NOTIFY MD IF PAIN PERSISTS IS GRADUAL PROGRESS ACTIVITY INCREASEINST DISCONTINUE ACTIVITY IF CHEST PAIN DYSPNEA FATIGUE OR PALPITATIONS OCCUR
Angina
PSYCHOLOGICAL ASSESSMENT ASSESS NEUROLOGICAL STATUS IMPLEMENT AND MONITOR BOWEL REGIMEN ampTEACH PROGRAM TO FAMILY SN TO MONITOR TRANQUILIZER EFFECTS GIVEN FOR SEVERE AGITATIONANXIETYEVALUATE FOR WEIGHT LOSS WEIGH PATIENT Q VISIT AND RECORDS WEIGHTS MONITOR LEVEL OFCONSCIOUSNESS ASSESS COORDINATION AND BALANCE PROVIDE EMOTIONAL SUPPORT TO PATIENT ANDFAMILY OBSERVATION AND EVALUATION OF BLADDER ELIMINATION HABITS MANAGEMENT IF INCONTINENCEASSIST FAMILY IN SETTING UP ROUTINE PATIENT-CENTERED AND STRESS THE IMPORTANCE OF ADHERING
Alzheimers
AIDE - ORDERS - FREQUENCYDURATIONTUBSHOWER BATH PERSONAL CARE HAIR COMB SHAMPOO PRN MOUTHDENTURE CARE SKIN CHECK ORAL HYGIENE TPRASSIST TO DRESS ASSIST WITH AMBULATION PREPARE SERVE MEALS GROCERY SHOP WASH CLOTHES LIGHT HOUSEKEEPING ASSIST WITH PERSONAL CARE AND ADLSERRANDS NOTIFY LAST BM IF NONE FOR 3 DAYS FEETNAILS CARE PERI CARE REPORT SIGNIFICANT FINDING TO SN STRAIGHTEN ROOM amp CHANGE LINEN
PT - ORDERS - FREQUENCYDURATIONEVALUATE BALANCE AND COORDINATION EVALUATE ENDURANCE MOBILITY NEUROMUSCULAR RE-EDUCATIONPERFORM PRESCRIBED THERAPEUTIC EXERCISES NOTIFY SIGNIFICANT FINDING TO MDAGENCY BED MOBILITY TRAININGGAIT TRAINING WITH ASSISTIVE DEVICE TEACH HOME MAINTENANCE PROGRAM AND STRENGTHENING EXERCISEEXERCISE BOTH PASSIVE AND ACTIVE EXERCISE REGIMEN TRANSFER TRAINING INSTRUCT IN SAFETY MEASURES FALL PRECAUTIONS
OT - ORDERS - FREQUENCYDURATIONEVALUATE PATIENT AND HOME FOR SAFETY ADL TRAINING PROGRAM MUSCLE RE-EDUCATION BODY IMAGE TRAININGINCREASE RIGHT AND LEFT UPPER EXTREMITIES STRENGTH THERAPEUTIC EXERCISE TO (R) AND (L) HANDINCREASE STRENGTH AND COORDINATION PROPRIOCEPTION AND SENSATION
ST FOR EVALUATION TO PROVIDE ORAL MOTOR EXERCISES INVOLVING LINGUAL AND LABIAL EXERCISES SPEECH ARTICULATION DISORDER TREATMENTIMPROVE SPEECH FACIAL SYMMETRY AND MUSCULATION IMPROVE DYSPHAGIA VOICE DISORDER TREATMENT AURAL REHABILITATION NON-ORAL COMMUNICATION LANGUAGE DISORDER TREATMENT
ST - ORDERS - FREQUENCYDURATION
MSW - ORDERS - FREQUENCYDURATIONMSW FOR ASSESSMENT OF SOCIAL AND EMOTIONAL FACTORS COMMUNITY RESOURCE PLANNINGCOUNSELING REGARDING MANAGEMENTADJUSTMENT TO ILLNESS LONG RANGE PLANNING AND DECISION MAKING
PROVIDE SUPPORTIVE AND RELAXATION THERAPY PROVIDE FAMILY THERAPY ASSESS INTERPERSONALBEHAVIOR ASSIST PATIENT TO DEFINE PROBLEMS amp SOCIAL RELATIONSHIPS GIVE POSITIVE REINFORCEMENTASSIST PATIENT TO VERBALIZE FEELINGS
Anxie ty
INST DISEASE PROCESS AND COMMON COMPLICATIONS INST LOW SODIUM DIET - STRESSING IMPORTANCE OFADHERENCE MONITOR PATIENTS BLOOD PRESSURE CLOSELY AND NOTIFY MD OF ANY SIGNIFICANT CHANGESINSTRUCT PT TO AVOID OVER-THE-COUNTER COLD AND SINUS MEDS AS THEY CONTAIN VASOCONSTRICTORINST OF HYPERTENSIVE CRISIS MONITOR FOR SS OF ORTHOSTATIC HYPOTENSION
Hypertension
ASSESS PSYCHOLOGICAL STATUS PROVIDE SUPPORTIVE THERAPY PROVIDE REMOTIVATION ASSESSINTERPERSONAL BEHAVIOR ASSIST PATIENT TO DEFINE PROBLEMS amp SOCIAL RELATIONSHIPS GIVE POSITIVEREINFORCEMENT ENCOURAGE PATIENT TO PERFORM PERSONAL HYGIENE amp GROOMING ACTIVITIESASSIST PATIENT TO EXPRESS REALISTIC IDEAS amp PLANS ASSIST PATIENT TO VERBALIZE FEELINGS
Depression
INSTRUCT PATIENT IN CONSEQUENT PHYSICAL L IMITATIONS PLANNING AN ADEQUATE LEVEL OF DAILYACTIVITIES TEACH PT RE ARTHRITIS SS OF EXACERBATION TEACH THE IMPORTANCE OF GOOD POSTUREPREVENT TRAUMA TO JOINTS INST PT IN THE USE OF ASSISTIVE DEVICE AS PRESCRIBED
Osteoarthritis
SKILLED OBSERVATIONEVALUATION ASSESS VITAL SINGS amp SS COMPLICATIONSINSTRUCTEVALUATE UNDERSTANDING OF DISEASE PROCESS DETECTING COMPLICATIONSDIETNUTRITIONAL STATUS SAFETY PRECAUTIONEMERGENCY MEASURES MED-REGIMEN
PSYCH ASSESSMENT ASSESS FOR SS OF EPSDETECT AND ALLEVIATE SOMATIZED COMPLAINTSLIMIT SETTING MOTIVATION TECHNIQUES IMAGERY TECHNIQUES
RELAXATION TECHNIQUESGOAL ORIENTED TASKS
FOLEY INSERTION _______FR FOLEY WITH___________cc BALLONCHANGE Q MONTH amp PRN x3 FOR CLOGGED LEAKING OR ACCIDENTAL REMOVALINST DRESSING CHANGES ________________________ MONITOR FOR SS COMPLICATIONS amp NOTIFY MD
INST SS INFECTION
MONITOR STATUS OF WOUND OR DECUBITUS (place) ______________INST INFECTION CONTROL MEASURES
INST GOOD NUTRITION TO FACILITATE HEALINGMEASURE AND RECORD WOUND or DECUBITUS SIZE AT SOC AND AT LEAST WEEKLY THEREAFTEROPEN WOUND CAREDRESSING CLEANSE WOUND WITH ___________ TO RINSE WITH __________ AND APPLY______________ AND PRN
OBSERVE AND RECORD TYPE AND AMOUNT OF DRAINAGE COLOR INFECTION SWELLING REDNESS PAINDE CUB ITUS CAR EDR ESS ING CLEAN SE W OUN D WITH ___________ TO R IN SE WITH __________ AN D APP LY ______________ AN D PR N
TEACH THE PATIENT HOW TO USE A METERED-DOSE INHALER MAINTAIN EFFECTIVE AIRWAY CLEARANCE
EMPHASIZE THE IMPORTANCE OF ADEQUATE DAILY FLUID INTAKE
PROMOTE AN EFFICIENT BREATHING PATTER
INST INFECTION CONTROL amp PULMONARY HYGIENE INST COMPLICATIONS IN CARDIOPULMONARY STATUSINST PREVENTION OF COMPLICATIONS IE AVOID OVER-EXERTION CHILLING CROWDS ETC
INST D ISEASE PROCESS amp MAINTENANCE
INSTRUCT COUGHING DEEP BREATHING EXERCISES INST PATIENT TO MAINTAIN ADEQUATE REST PATTERN
MANAGEMENT AND EVALUATION OF A PATIENT CARE PLAN TEACHING AND TRAINING DISEASE PROCESS SKIN CARE WOUND CAREDRESSING CHANGE DECUBITUS CARE MEDICATION REGIMEN DIETNUTRITIONHYDRATION COMPLICATIONS OF ENT FEEDING AS INDICATED
PAIN CONTROL MEASURES SYMPTOM CONTROL MEASURES SINGSSYMPTOMS OF INFECTION SAFETYPREVENTION OF INJURY EMERGENCY PLANS OXYGEN ADMINISTRATION
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GOALSREHABILITATION POTENTIAL CMS485 (POC)Included as reference only your Professional Staff must reviewupdatepersonalizeapprove the goals
DISCHARGE PLANNING DISCUSSED WITH PATIENT Yes No REHAB POTENTIAL ExcellentPoor Fair Good
SIGNATUREDATES
X DateStaff Completing the OASIS (signaturetitle)
OASIS INFORMATION
Data Entry Date amp Locked Date SubmittedQA Date Reviewed
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SN - GOALSMRMS _________________ WILL EXHIBIT VITAL SIGNS WITHIN ACCEPTABLE RANGE AND STABILIZED DISEASE PROCESSVERBALIZES KNOWLEDGE OF DISEASE MANAGEMENT MEDICATIONS SIDE EFFECTS PRECAUTIONS DIET FLUIDS TREATMENT PROGRAM SS NECESSITATING MEDICAL ATTENTION EMERGENCY CARE
STABILIZATION OF PSYCHOLOGICAL STATUS WITHIN DISEASE LIMITS TO REDUCE THE PATIENTS ANXIETY LEVELDEPRESIONANXIETY CONTROLED TROUGH MED REGIMEN INTERVENTIONS
ANEMIA CONTROLLED THROUGH MED REGIMEN IMPROVED HEMATOLOGIC STATUS
General
Psychiatric
A n e m i aHEALED WOUND WITHOUT INFECTION OR COMPLICATIONS DEMONSTRATE PROPER WOUND CARE
Wound Care
PTSO SHOULD UNDERSTAND THE NATURE SYMPTOMS STAGE AND PROGRESSION OF ALZHEIMERS DISEASEKNOW HOW TO RECOGNIZE PTS OWN STRESS AND WAYS TO PREVENT OR REDUCE IT PROMOTE SOCIAL INTERACTION AS TOLERATED BY THE PATIENT
Decubitus
DEMONSTRATE STRATEGIES TO BE USED DURING A COUGHING EPISODE HELP THE PATIENT IDENTIFY FACTORSTHAT MAY CAUSE ASTHMA ATTACKS OR CONTRIBUTE TO THEMAsthma
SAFELY ADMINISTERS INJECTION COMPREHEND RATIONALE FOR AND IS ABLE TO ROTATE INJECTION SITESCOMPREHEND SAFETY FACTORS IN SYRINGENEEDLE DISPOSALPATIENTCG ABLE TO MONITOR BLOOD SUGAR CORRECTLY WITHOUT ASSISTANCEABLE TO NOTIFY MD OF ALTEREDOUT OF RANGE RESULTS
InsulinGlucometer
DISCHARGE PT WHEN BLOOD SUGARS ARE WITHIN THE NORMAL FOR PATIENT RANGEKNOW THE ACCEPTABLE RANGE FOR BLOOD SUGAR LEVEL COMPLY WITH DIET RESTRICTIONS Diabetes
MellitusRETURN TO SELF-MANAGEMENT OF HEALED FRACTURED
FractureKNOW ABOUT SIGNS SYMPTOMS AND PRECIPITATING CAUSES OF CHF KNOW HOW TO TAKE THE PULSE AND KNOWTO CONSULT THE DOCTOR BEFORE CONTINUING MEDICATION IF THE PULSE RHYTHM CHANGES KNOW TOA V O I D S M O K I N G A N D S M O K Y E N V I R O N M E N T S A N D P E R S O N S W I T H I N F E C T I O N S E S P E C I A L L Y R E S P I R A T O R Y I N F E C T I O N S
CHF
UNDERSTAND THAT HYPERTENSION IS A CHRONIC DISEASE REQUIRING LIFE LONG TREATMENT EXHIBIT BLOODPRESSURE READINGS CONSISTENTLY WITHIN NORMAL OR SPECIFIED RANGE DEMONSTRATE ADHERENCE TO ALOW-SALT LOW-FAT DIET
Hypertension
HELP THE PATIENT ACHIEVE PAIN RELIEVE AND REDUCE ANGINA EPISODES UNDERSTAND THE CAUSE OFANGINA PECTORIS AND POSSIBLE PRECIPITATING FACTORS FOR AN ATTACK IDENTIFY PERSONAL STRESSORSTHAT MAY CONTRIBUTE TO THE PROBLEM AND BEGIN ELIMINATING OR MINIMIZING THEM KNOW WAYS TOREDUCE THE FREQUENCY OF ANGINA EPISODES
Angina
HEALED DECUBITUS WITHOUT INFECTION OR COMPLICATIONS DEMONSTRATE PROPER DECUBITUS CARE
Alzheimers
UNDERSTAND SS OF BRONCHITIS OR OTHER RESPIRATORY INFECTION AND DISEASE EXACERBATIONUNDERSTAND THE DANGERS OF SMOKING AIR AND CHEMICAL POLLUTANTS AND RESPIRATORY INFECTIONUNDERSTAND AND PRACTICE COUGHING AND DEEP-BREATHING EXERCISES
Respiratory
DAILY COMPLIANCE WCATHETER CARE DECREASE RISK OF URINARY INFECTIONCatheter
INCREASED PAIN RELIEF INCREASED STRENGTH AND ENDURANCE COMPREHEND AND DEMONSTRATE HOME EXERCISEOsteoarthritis
AIDE - GOALS
GAIT PATTERN ENDURANCE STRENGTH AND BALANCE WILL IMPROVE AND PATIENT WILL DEMONSTRATECORRECT BODY MECHANICS WIN 4-6 WKS PTCG WILL COMPREHEND AND DEMONSTRATE HOME EXERCISEPROGRAM WITHIN 4-6 WKS
FAIR-TO BE ABLE TO CARRY OUT MINIMAL ADLS WITH AVAILABLE HOME SUPPORTWILL NOT BE ABLE TO CARRY OUT ADLS WITHOUT MAXIMUM SUPPORT
RETURN TO INDEPENDENT AMBULATION BE SAFE IN SELF CAREPATIENT WILL BE ABLE TO FUNCTION WITH ASSISTANCE OF CAREGIVERWITHIN HESHE CURRENT LIMITATIONS AT HOME
PATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HISHER CURRENT LIMITATIONS AT HOME
PT - GOALS
GOOD RETURN TO PREVIOUS LEVEL OF ADLS INDEPENDENTLY
GAIT PATTERN ENDURANCE STRENGTH AND BALANCE WILL IMPROVE AND PT WILL DEMONSTRATECORRECT BODY MECHANICS WITHIN _____ WEEKS
PATIENT WILL EXPERIENCE A DECREASE IN PAIN
PTCG WILL COMPREHEND AND DEMONSTRATE HOME EXERCISEPROGRAM WITHIN _____ WEEKS
OT PATIENT WILL EXHIBIT IMPROVEMENT IN COPING IN ADLSIADLS MUSCLE USEMOTORCOORDINATIONNEURO RESPONSEUSE OF ORTHOTIC SPLINTING ANDOR EQUIPMENT
OT - GOALS
PATIENT WILL DEMONSTRATE FUNCTIONAL COMMUNICATIONS EXHIBIT MAXIMUM VERBAL AND SENTENCEFORMULATION AND COMPREHENSION WITHIN DISEASE LIMITS WITHIN _____ WEEKS
ST - GOALS
PATIENT WILL DEMONSTRATE APPROPRIATE USE OF FUNCTIONAL VERBALNON-VERBALCOMMUNICATIONS SYSTEMS WITHIN _____ WEEKS
PATIENT WILL DEMONSTRATE IMPROVED READINGWRITING USE OF GESTURESNUMBERS WITHIN _____ WEEKS
PATIENT WILL DEMONSTRATE IMPROVED SWALLOWINGCHEWINGORALMOTOR CONTROL WITHIN _____ WEEKS
PATIENT WILL HAVE ADEQUATE SUPPORT TO REMAIN IN HOME WITH ASSISTANCE OF COMMUNITYRESOURCES FOR FINANCIAL TRANSPORTATION AND PERSONAL CARE ASSISTANCE WITHIN _____ WEEKS
MSW - GOALSPSYCHOSOCIAL EVALUATION WILL BE PERFORMED PTCG WILL BE COUNSELED REGARDING MANAGEMENTamp ADJUSTMENT TO ILLNESS LONG TERM PLANNING AND DECISION MAKING APPROPRIATE COMMUNITYRESOURCE REFERRALS WILL BE MADE
WILL DISCHARGE THE PATIENT WITHIN 60 DAYS WHEN PATIENT ANDORCAREGIVER ISARE ABLE TO DEMONSTRATE KNOWLEDGE OF DISEASE MANAGEMENT SS COMPLICATIONSPATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HISHER CURRENT LIMITATION AT HOME
ABLE TO REMAIN IN HOMERESIDENCEALF WITH ASSISTANCE OF PRIMARY CAEGIVERSUPPORT AT HOMEABLE TO UNDERSTAND MEDICATION REGIMEN AND CARE RELATED TO HISHER DISEASEWILL BE DISCHARGE WHEN MAXIMUM FUNCTIONAL POTENTIAL REACHED
Patient Name Med Record
wwwpnsystemcom 3058185940 The Outcome and Assessment Information Set (OASIS) is the intellectual property of the Center for Health Services and Policy Research Denver Colorado It is used with permission Expiration date 7312012
XPatient Signature if required optional if itinerary is used
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- OASIS_C_SOC
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- PT ID PERFORMED VIA NAME DOB FACE RECOGNITION AND ADDRESS BEFORE SERVICE PROVIDED Off
- TIME IN
- TIME OUT
- Agency Name SALUD HOME CARE INC
- Phone 305-555-5555
- Employees NameTitle Completing the OASIS
- who has signed the plan of care
- Physician name
- Address 1
- Address 2
- Phone Number
- Address 1_2
- Address 2_2
- Patient Phone
- Reason
- Name
- Other Physician if any
- Phone_2
- Address 1_3
- Address 2_3
- Phone Number_2
- REFERRAL SOURCE if not from Primary Physician
- undefined_6
- Phone_3
- Fax
- Evacuation Form needed Emergency Reg 1
- Evacuation Form needed Emergency Reg 2
- EMERGENCY CONTACT
- Address
- Comments 1
- Comments 2
- Phone_4
- Relationship
- OTHER
- Comment 1
- Comment 2
- 11 Other specify
- a
- b
- 7 Other specify
- c
- d
- e
- f
- a_2
- b_2
- d_2
- e_2
- f_2
- a_3
- b_3
- d_3
- Comment if needed 1
- Comment if needed 2
- a_4
- a_5
- a_6
- Date 23
- undefined_7
- undefined_8
- b_4
- b_5
- b_6
- Date_2
- undefined_9
- undefined_10
- Date_3
- undefined_11
- undefined_12
- d_4
- d_5
- d_6
- Date_4
- undefined_13
- undefined_14
- Date_5
- undefined_15
- undefined_16
- Date_6
- undefined_17
- undefined_18
- 12 1
- 12 2
- Date_7
- undefined_19
- undefined_20
- Date_8
- undefined_21
- undefined_22
- MAIN REASON FOR HOME HEALTH CARE 1
- MAIN REASON FOR HOME HEALTH CARE 2
- Fractures site
- Surgeries site
- Cancer site
- Open Wound site
- Decubitus site
- Other specify
- Other
- Pending or Needed
- Yes Number of times
- Reason s Dates
- MobilityAmbulatory devices used
- Other specify_2
- undefined_23
- Comments if needed 1
- Comments if needed 2
- Comments if needed 3
- Comments if needed 4
- undefined_24
- Name_2
- Phone number if different from patient
- Relationshiphealth statusability to help 2
- Any paid help explain
- Specify 1
- Specify 2
- Specify 3
- Any ears surgeryprocedure
- Date_9
- Otherspecify 1
- Otherspecify 2
- Other agencies involved in care 1
- Other agencies involved in care 2
- 1
- 2
- Other_2
- Infections
- Cataract surgery Site
- Date_10
- Other eyes surgery Site
- Date_11
- explain 1
- explain 2
- Any nose surgery
- Date_12
- Other specify_3
- 1_2
- 2_2
- MassesTumors site
- Lesions explain
- Any surgeryprocedure
- Other specify 1
- Other specify 2
- Other specify 3
- Date_13
- Other specify_4
- No Problem
- Medication
- Other_3
- Pain control treatmentmeds Side effect mark
- Other_4
- Is there a regular pattern to the pain explain
- Other_5
- Comment
- What was the outcome
- Type II OnsetExacerbation date
- DietOral control specify
- INSULIN dosage frequency scale explain
- 1_3
- 2_3
- Since
- Other_6
- A1c
- BS
- mgdL DateTime
- Blood sugar ranges
- site 1Location site
- site 2Location site
- site 3Location site
- Frequency
- Other_7
- site 1New Onset Exacerbation
- site 2New Onset Exacerbation
- site 3New Onset Exacerbation
- Able to use Glucometer
- site 1Present level 010
- site 2Present level 010
- site 3Present level 010
- Diabetes Management Problems explain 1
- Diabetes Management Problems explain 2
- Other Endocrine problems
- site 1Occasional y Cont Intermittent Frequency Frequently
- site 2Occasional y Cont Intermittent Frequency Frequently
- site 3Occasional y Cont Intermittent Frequency Frequently
- site 1Pain type ach ng burn ng rad ating neura gia etc
- site 2Pain type ach ng burn ng rad ating neura gia etc
- site 3Pain type ach ng burn ng rad ating neura gia etc
- Anemia specify type if known
- site 1Feeling of pain internal external acute chronic
- site 2Feeling of pain internal external acute chronic
- site 3Feeling of pain internal external acute chronic
- site 1Pain is worse morning
- site 2Pain is worse morning
- site 3Pain is worse morning
- Immunodeficiency problems explain
- Other 1
- Other 2
- Other_8
- explain 1_2
- explain 2_2
- explain 3
- explain 4
- Other specify 1_2
- Other specify 2_2
- undefined_25
- undefined_26
- undefined_27
- undefined_28
- undefined_29
- undefined_30
- undefined_31
- undefined_32
- undefined_33
- undefined_34
- undefined_35
- undefined_36
- M1310 Pressure Ulcer Length Longest length headtotoe
- undefined_37
- cm
- greatest width perpendicular to the length
- M1314 Pressure Ulcer Depth Depth of the same pressure ulcer from
- cm_2
- visible surface to the deepest area
- undefined_38
- cm_3
- 1_4
- 2_4
- 3_2
- Other_9
- 4_2
- Caregiver name
- Other_10
- cant integument findings
- Observation
- Observation_2
- Caregiver name_2
- Other_11
- Wound cleaned with specify
- Wound irrigated with specify
- 1 Size
- cm width
- Wound packed with specify
- Location
- Other_12
- Wound dressingcover applied specify
- 2 Size
- cm width_2
- Comments 1_2
- Comments 2_2
- Location_2
- Other_13
- Sizecm LengthxWidthxDepth
- Sizecm LengthxWidthxDepth_2
- Diagram 4Sizecm LengthxWidthxDepth
- Tunneling Undermining cm
- Tunneling Undermining cm_2
- Diagram 4Tunneling Undermining cm
- Stage IIIIIIIV pressure uIcers only
- Diagram 4Stage IIIIIIIV pressure uIcers only
- Odor Fool normal etc
- Diagram 4Odor Fool normal etc
- Edema pedal sacral p tting etc
- Diagram 4Edema pedal sacral p tting etc
- Appearance of the Wound Bed
- Diagram 4Appearance of the Wound Bed
- Treatment Ordered
- Diagram 4Treatment Ordered
- Other_14
- Other_15
- Other_16
- Other_17
- Yes 1
- Yes 2
- Yes 3
- Height
- Weight
- Radiating to
- GainLoss
- lb X
- Frequencyduration
- Sittinglying R
- L
- Standing R
- L_2
- Medication_2
- Temperature
- Other_18
- Apical
- Brachial
- Radial
- Carotid
- Dependent
- Pitting 1234
- Respirations
- Site
- Cramps site
- Disease Management Problems explain
- Right Upper
- Right
- Right Lower
- 1_5
- 2_6
- 3_3
- Left
- Left Upper
- Left Lower
- Pacemaker Date
- Last date checked
- SOB on minimal effortwalk
- Type
- fy
- Other Prob 1
- Other Prob 2
- O2
- Trach sizetype
- CaregiverfamilyOther
- Yes explain 1
- Yes explain 2
- Other_19
- Comments 1_3
- Comments 2_3
- Increase fluids
- Restrict fluids
- Frequency_2
- Amount
- Yes describe 1
- Yes describe 2
- Frequency_3
- Other 1_2
- Other 2_2
- Nocturia x
- Bowel Off
- undefined_52
- Diapersother
- Other_20
- No
- 2TOTAL
- Urinary Catheter Type
- Last changed on
- Foley inserted date
- with
- Inflated balloon with
- Irrigation solution Type specify
- Amount_2
- mL Frequency
- Returns
- No_2
- 1_6
- 2_7
- Describe at risk intervention and plan 1
- Describe at risk intervention and plan 2
- Describe at risk intervention and plan 3
- DischargeDrainage describe
- Lesions
- Blisters
- Masses
- Cysts
- Wart
- Other specify_5
- Surgical alteration
- Prostate problem BPH TURP Date
- undefined_53
- undefined_54
- Selftesticular exam Frequency
- Hysterectomy Date
- undefined_55
- undefined_56
- Date last PAP
- undefined_57
- undefined_58
- Results
- Breast selfexam frequency
- Mastectomy R L Date
- undefined_59
- undefined_60
- Other specify_6
- Last BM
- Diarrhea Frequency
- Bowel regimeprogram
- Incontinence Off
- Urinary Off
- Diapersother_2
- Other_21
- te describe skin around stoma
- Ileostomycolostomy s 2
- Ileostomycolostomy s 3
- Ileostomycolostomy s 4
- Ileostomycolostomy s 5
- Headache Location
- Frequency_4
- Other_22
- Migraine Frequency
- Site_2
- Weakness UE LE Location
- Other specify_7
- Site_3
- IV
- Pump typespecify
- Hand grips Equal Unequal specify
- Feedings Type amtrate
- Strong Weak specify
- Psychotropic drug use specify
- Flush Protocol amtspecify
- DoseFrequency
- Other_23
- Other specify 1_3
- Other specify 2_3
- DressingSite care specify 1
- DressingSite care specify 2
- Interventions instructionsComments 1
- Interventions instructionsComments 2
- Following Un
- versalStandard precautions
- NA
- No Problem_2
- Pain Frequency
- Abdominal girth
- Bowel sounds active absent hypo hyperactive x
- 3 Forgetful Off
- 4 Depressed Off
- 6 Lethargic Off
- 5 Disoriented Off
- 7 Agitated Off
- 2 Comatose
- 8 Other Off
- Forgetful at times Off
- Irritable Off
- Anxious Off
- Alert Off
- Describe 1
- Describe 2
- undefined_61
- Needs interpreter
- Comments 1_4
- Comments 2_4
- Higher Educational Level
- Fracture location
- Swollen painful joints specify
- Explain
- Contractures Joint
- Spiritual resource
- Location_3
- Phone No
- Atrophy
- Other_27
- Explain 1
- Explain 2
- Decreased ROM
- Paresthesia
- Weakness
- Other_28
- Inappropriate followthrough in past
- Amputation BKAKUE RL specify 1
- Amputation BKAKUE RL specify 3
- Amputation BKAKUE RL specify 4
- Treatment
- Treatment_2
- Other specify 1_4
- Other specify 2_4
- History of Falls past 3 months 12 falls M1032
- V s on Status Poor w or w o glasses M1200
- Vision Status Poor Legally blind M1200
- Gait and Balance Balance problem while standing
- Gait and Ba ance Balance problem while walking
- Gait and Balance Decreased muscular coordination
- Pred spos ng D seases 12 present
- Predisposing D seases 3 or more present
- Equipment Issues Oxygen tubing
- 1Row1
- PlanComments 1
- PlanComments 2
- Comment_2
- undefined_62
- b Ambulation
- c Transfer
- DOther specify
- 7Independent in home 1
- 7Independent in home 2
- Other 1_3
- Other 2_3
- Typebrand
- Size
- Gauge
- Length
- Insertion site
- Insertion date
- Flush solution
- Frequency_5
- Injection cap change frequency
- Dressing change frequency
- Other_29
- Siteskin condition
- External catheter length
- OtherComment
- fluid overload Other
- Circumference of arm
- Huber gaugelength
- Yes date
- Last flushed date
- Siteskin condition_2
- Infusion solution typevolumerate
- Dressing
- OtherComment 1
- OtherComment 2
- Drug Name
- Dose
- Route
- Frequency_6
- Duration of therapy
- Drug Name_2
- Dose_2
- Route_2
- Frequency_7
- Duration of therapy_2
- CommentPlan 1
- CommentPlan 2
- Pump type specify
- Other_30
- Lab draws
- Infusion care provided during visit 1
- Infusion care provided during visit 2
- Infusion care provided during visit 3
- Antibiotic therapy
- 1_7
- 2_8
- Other_31
- Removing line date if know
- BraceOrthotics specify 1
- BraceOrthotics specify 2
- BraceOrthotics specify 3
- Needs specify 1
- Needs specify 2
- Oxygen HME Co
- Prosthesis RUE RLE LUELLEOther
- HME Rep
- Grab bars BathroomOther
- Hospital bed Semielec Crank Spec
- Other_32
- NA_2
- Phone_5
- n care
- PlanComments
- N
- Other_33
- undefined_63
- Physical Therapy Total visits
- Speech Therapy Total visits
- visits
- Other Therapy Total visits
- Patient is not assessed to be at risk for falls
- No pain identified
- Patient has no pressure ulcers with need for moist wound healing
- O
- Noncompliance with drug orders
- Expected Outcome
- Patient unable to perform own Wound Care due
- Pat
- to
- Abd Pads Off
- Underpads size
- undefined_68
- Special mattress overlay
- Angiocatheter size
- Ostomy pouch brand size
- Pressure relieving device
- Ostomy wafer brand size
- undefined_69
- SYRINGES
- Batteries size
- Skin protectant
- Glucometer
- Hydrocolloids
- undefined_70
- FOLEYCATH SUPPLIES
- Syringes size
- size
- Oxygen concentrator
- Feeding tube
- Ointment
- Acetic acid
- Other 1_4
- Other 2_4
- Other 3
- Tens unit
- KLING 4
- Other 1_5
- Other 2_5
- Other 3_2
- PatientCG educationteaching this visit for
- MEDICATION Off
- DISEASE PROCESS COMPLICATIONS Off
- undefined_71
- SS OF Off
- ILEAL CONDUITOSTOMY Off
- DIET FLUIDS Off
- undefined_72
- undefined_73
- SKINFOOT CARE Off
- INFECTION CONTROL Off
- OTHER INSTRUCTIONS GIVEN
- Caregiver present during the visit
- NEEDS FURTHER TEACHING Off
- No_3
- Skilled Observation Assessment
- ent Educat
- Wound Care Dress
- Diabetic Observation Care
- Correct handwashing technique followed SG 1
- Correct handwashing technique followed SG 2
- Correct handwashing technique followed SG 3
- Correct handwashing technique followed SG 4
- 21 Included as reference only your Professional Staff must reviewupdatepersonalizedapprove the orders
- SN ORDERS FREQUENCYDURATION
- S COMPLICATIONS
- TH GLUCOMETER OR
- ON
- TEACH GLUCOMETER OR
- NSERTION
- TH
- INST DRESSING CHANGES
- MONITOR STATUS OF WOUND OR DECUBITUS place
- ADMINISTER PRESCRIBED INJECTABLE
- USING
- TH_2
- TH_3
- AND APPLY
- CLEANSE WOUND WITH
- NSE WITH
- AND APPLY_2
- OTHER_2
- DE ORDERS FREQUENCYDURATION
- PT ORDERS FREQUENCYDURATION
- OT ORDERS FREQUENCYDURATION
- ST ORDERS FREQUENCYDURATION
- MSW ORDERS FREQUENCYDURATION
- Included as reference only your Professional Staff must reviewupdatepersonalizeapprove the goals 22
- MRMS
- PROGRAM WITHIN
- CORRECT BODY MECHANICS WITHIN
- COMMUNICATIONS SYSTEMS WITHIN
- undefined_75
- undefined_76
- Date_14
- QA Date Reviewed
- undefined_77
- undefined_78
- Data Entry Date Locked
- undefined_79
- undefined_80
- Date Submitted
- undefined_81
- undefined_82
- SOCD
- SOCM
- SOCY
- SOCM1
- SOCD1
- SOCY1
- Check Box2 Off
- Check Box3 Off
- Check Box4 Off
- TOM
- TOD
- TOY
- FDM
- FDD
- FDY
- Prov 1071523
- BrID
- Check Box9 Yes
- BrIDno
- Check Box11 Off
- DLCM
- DLCD
- DLCY
- LVM
- LVD
- LVY
- DNR1 Off
- Check Box19 Off
- STFL
- PZC
- MCN
- NOMC Off
- SSN1
- SSN2
- SSN3
- SSUK Off
- MAN
- MAUK Off
- DOBM
- DOBD
- DOBY
- SEX Off
- MR
- First
- MI
- Last
- Suffix
- RACE2 Off
- RACE3 Off
- RACE4 Off
- RACE5 Off
- RACE1 Off
- RACE6 Off
- PS3 Off
- PS0 Off
- PS1 Off
- PS4 Off
- PS5 Off
- PS6 Off
- PS7 Off
- PS8 Off
- PS9 Off
- PS10 Off
- PS11 Off
- PS2 Off
- PSUK Off
- Ecode
- COMP Off
- DACM
- DACD
- DACY
- REA Off
- DM
- DD
- DY
- RDM
- RDD
- RDY
- REFDM
- REFDD
- REFDY
- EPT Off
- 14D2 Off
- 14D3 Off
- 14D4 Off
- 14D5 Off
- 14D6 Off
- 14D7 Off
- 14D8 Off
- Check Box39 Off
- icd9c
- icd9a
- icd9b
- icd9d
- icd9e
- icd9f
- Check Box5 Off
- Check Box7 Off
- icd9b2
- icd9c2
- icd9d2
- C_2
- icd9e2
- icd9f2
- icd9a2
- icd9b3
- icd9c3
- C_3
- icd9a3
- icd9d3
- 1005d
- 1005m
- 1005y
- 1018-2 Off
- 1018-1 Off
- 1018-4 Off
- 1018-5 Off
- 1018-6 Off
- 1018-7 Off
- 1018-NA Off
- 1018-UK Off
- 1018-3 Off
- 1012-na Off
- 1012-uk Off
- Radio Button11 Off
- v1020b
- C_5
- e_5
- f_5
- C_6
- e_6
- f_6
- c_4
- e_4
- f_4
- v1020c
- v1020d
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- e1020a
- ev1020b
- ev1020c
- ev1020d
- ev1020e
- ev1020f
- ev1020a
- sp12-1
- sp12-2
- Radio Button12 Off
- Radio Button13 Off
- rad0 Off
- rae0 Off
- rdf0 Off
- phhp Off
- phrp1 Off
- phot1 Off
- phoa1 Off
- phfc1 Off
- phca1 Off
- phin1 Off
- phga1 Off
- phif1 Off
- phsg1 Off
- phwd1 Off
- phdc1 Off
- phgn1 Off
- rddmi Off
- imin Off
- inh1n1 Off
- fwpn Off
- fwtn Off
- fwot Off
- phdm1 Off
- PHNY Off
- phcd1 Off
- 10304 Off
- 10301 Off
- 10302 Off
- 10303 Off
- 10327 Off
- M1034 Off
- HBR1 Off
- HBR2 Off
- HBR3 Off
- HBR4 Off
- HBR5 Off
- HBR6 Off
- HBR7 Off
- HBR8 Off
- HBR9 Off
- HBR11 Off
- HBR12 Off
- HBR10 Off
- HBR13 Off
- SOBFT
- 10321 Off
- 10322 Off
- 10333 Off
- 10324 Off
- 10325 Off
- 10336 Off
- M11001 Off
- M1100b Off
- M1100c Off
- Relationshiphealth statusability to help 1
- 10361 Off
- 10362 Off
- 10363 Off
- 10364 Off
- 10365 Off
- 10366 Off
- 1210d Off
- 1210an Off
- 1210hea Off
- 1210OTH Off
- 1210TIN Off
- 1210NP Off
- 12102 Off
- 12101 Off
- 1210uk Off
- 1210h Off
- 1210v Off
- 1200CAT Off
- 1200OTH Off
- 1200JA Off
- 1200CATRL Off
- 1200OTHER Off
- 1200PT Off
- 1200GLAU Off
- 1200NOP Off
- NOSECON Off
- NOSEEP Off
- NOSELS Off
- NOSESINP Off
- NOSEASG Off
- NOSEOTHSP Off
- NOSENP Off
- THROATDY Off
- TROATL Off
- THROATOTH Off
- 1200BV Off
- 1200LB Off
- THROATHO Off
- THOATSO Off
- THROATNP Off
- 1200GL Off
- 1200CO Off
- 1200PR Off
- 1200IN Off
- M1200 Off
- M1220 Off
- M1230 Off
- MOUTHMas Off
- MOUTHGI Off
- MOUTHULC Off
- MOUTHTOO Off
- MOUTHANY Off
- MOUTHOTH Off
- MOUTHNP Off
- M1240 Off
- M1242 Off
- MOUTHDE Off
- MOUTHUP Off
- MOUTHLO Off
- MOUTHPAR Off
- COPYN Off
- MKMEDP Off
- CPCYN Off
- DPRYN Off
- ICPYN Off
- TURGGP Off
- BESTPAINSC2
- WORSES2
- BESTPAINSC
- WORSESC
- BESTPAINSC3
- WORSESC3
- FACESOBS Off
- SCALE010 Off
- WPSL Off
- WPMA Off
- WPMV Off
- WPAMB Off
- WPIMM Off
- WPTR Off
- WPOTH Off
- WPNP Off
- NVIM Off
- WRP4 Off
- WRP5 Off
- WRP6 Off
- WRP7 Off
- WRP8 Off
- WRP9 Off
- WRPOTH Off
- TKMEDNV Off
- TKMEDLDD Off
- TKMEDD Off
- TKMED23 Off
- TKMEDLT3 Off
- PCTSL Off
- PTXSEN Off
- PTXSEV Off
- PTXSECF Off
- PRDOCC Off
- PTXSEOTH Off
- PRDCONT Off
- WRP1 Off
- WRP2 Off
- WRP3 Off
- PRDINT Off
- PRDFRQ Off
- PHYNOTPT Off
- PHYNOTSTF Off
- NVIG Off
- NVIC Off
- NVIAF Off
- DMIJUV Off
- DMTPII Off
- INSDGFQ Off
- DMODIET Off
- ADMOTH Off
- symphyg Off
- sympfat Off
- symhypog Off
- endopcgr Off
- endopostpra Off
- endorand Off
- endolab Off
- bsrange Off
- bsranptcg Off
- endomonsf Off
- endomoncg Off
- endomonsn Off
- endomonoth Off
- dmNapb Off
- othendopb Off
- enlthyr Off
- intoheatcol Off
- endonp Off
- HEMAANE Off
- HEMABLEED Off
- HEMAHEMO Off
- HEMAINMO Off
- HEMAOTH Off
- HEMANP Off
- SKINITCH Off
- SKINRASH Off
- SKINDRY Off
- SKINSCL Off
- SKINRED Off
- SKINBRU Off
- SKINECCH Off
- SKINPALL Off
- SKINJAU Off
- ADMSELF Off
- ADMSCGF Off
- ADMNURS Off
- SKINNP Off
- m1300 Off
- M1302 Off
- M1306 Off
- M1320 Off
- M1322 Off
- M1324 Off
- M1330 Off
- M1332 Off
- M1334 Off
- M1340 Off
- M1342 Off
- M1350 Off
- WCPYN Off
- IPDMYN Off
- APHYN Off
- SDRBY Off
- SDRSN Off
- SDRCG Off
- SDRPT Off
- SDROTH Off
- TECST Off
- TECCL Off
- WDCLW Off
- WDIRRW Off
- WDPKW Off
- WDDREW Off
- DBFEXD Off
- DBFEX2D Off
- DBFEXEOD Off
- DFEX2WK Off
- DBNFEXWK Off
- DFEXOTH Off
- PDPPRL Off
- PDPARL Off
- LSWRL Off
- endobm Off
- endotv Off
- fbs Off
- LSCDRL Off
- ASCCFR Off
- ASCCFL Off
- Right for
- ASCCFLF
- TRINR Off
- BURRL Off
- LEGHP Off
- LEGHAB Off
- DBFEXRN Off
- DFEXCG Off
- DBFEXPT Off
- DBFEXOT Off
- EXSER Off
- EXSERG Off
- EXSANG Off
- EXSER2 Off
- EXSERG2 Off
- EXSANG2 Off
- SHOV Off
- SHAPRD Off
- SHAPOTH Off
- SHOV2 Off
- SHAPRD2 Off
- SHAPOTH2 Off
- cm length
- cm length2
- DBFTEXRNPT Off
- EXDYN Off
- EXDYN2 Off
- APHYN2 Off
- APHYN3 Off
- Loc3w
- Loc2w
- Loc1w
- Loc4w
- Typew1
- Typew2
- Typew3
- Typw4
- sizw3
- tunnw3
- surrw1
- stomaw1
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- stomaw1a
- surrw3
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- surrw2
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- stomaw2
- stomaw2a
- surrw4
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- stomaw4
- stomaw4a
- statgew2
- statgew3
- Odorw2
- Odorw3
- Edemaw2
- Edemaw3
- appw2
- appw3
- Treatment Ordered_2
- Treatment Ordered_3
- Group10 Off
- draick2 Off
- driack3 Off
- draick4 Off
- colw11 Off
- colw12 Off
- colw31 Off
- colw32 Off
- colw33 Off
- colw34 Off
- colw21 Off
- colw22 Off
- colw23 Off
- colw24 Off
- colw43 Off
- colw44 Off
- ital1u1 Off
- ital1u2 Off
- fsrrepo Off
- frsact Off
- rwgchpt Off
- rwgchcgf Off
- rwgchnur Off
- pulreg1 Off
- pulirreg1 Off
- fsrrespreg Off
- colw41 Off
- colw42 Off
- bpsitly Off
- bpstand Off
- fsrwgrep Off
- fsrwgact Off
- tempaxil Off
- temptymp Off
- pulseappical Off
- pulseradial Off
- pulsebrach Off
- pulsecarot Off
- pulserest Off
- pulsecheyn Off
- pulseactiv Off
- respirirreg Off
- respideath Off
- respaccess Off
- respiapnea Off
- bsckrack Off
- temporal Off
- temprect Off
- chestprad Off
- colw13 Off
- colw14 Off
- consth2 Off
- consthic2 Off
- consth3 Off
- consthic3 Off
- consth4 Off
- consthic4 Off
- chestpyes Off
- chestpainno Off
- consth1 Off
- consthic1 Off
- cpsubstern Off
- cpviselike Off
- dm5lin
- assocwithsoboe Off
- associawactv Off
- associwsweat Off
- cphowreloth Off
- cphowrelrest Off
- cphowrelmeds Off
- cppalarr Off
- cppalpfast Off
- cppalpslow Off
- cppalpfatig Off
- cpedema Off
- cpedemapedal Off
- cpangina Off
- cppostural Off
- cplocalized Off
- cpedempedrig Off
- cpedemapedallef Off
- cpedemasacral Off
- cpedemadepend Off
- cpedemapitt Off
- cpedemanonpitt Off
- cstcramp Off
- cardstclaud Off
- cardstcapref Off
- cstcaprefless Off
- castcaprefgreat Off
- csthsreg Off
- csthsirreg Off
- csthsmurmur Off
- cstpacemak Off
- cpstabreassouclear Off
- breassodwheez Off
- bresddimm Off
- chestpaidull Off
- cpache Off
- cpsharp Off
- brsdabset Off
- brsdsobsoboe Off
- brsdsobonmineff Off
- 14001 Off
- 14003 Off
- 14004 Off
- 1400tva Off
- 14002 Off
- 1400car Off
- 14101 Off
- 14102 Off
- 14103 Off
- 14104 Off
- uroops Off
- uropat Off
- urocare Off
- 14000 Off
- urosn Off
- Radio Button2 Off
- 16100 Off
- 16101 Off
- 1400pat Off
- 16concar Off
- 162gm Off
- 16nas Off
- 16npo Off
- 16102 Off
- 161800cal Off
- 16lowfat Off
- 16lowcho Off
- 16incflu Off
- 16restflu Off
- 16exc Off
- 16good Off
- 16fair Off
- 16poor Off
- 16anore Off
- 16nau Off
- 16vom Off
- 16heabur Off
- O2satur
- O2firesaf Off
- O2sn Off
- O2carefamother Off
- O2cough Off
- O2no Off
- O2yes Off
- O2nonprod Off
- O2noc Off
- O2yesc Off
- O2dys Off
- O2rest Off
- O2dADL Off
- O2sliplo Off
- O2nop Off
- O2yesp Off
- 16other Off
- genibur Off
- genihes Off
- genihema Off
- geniolig Off
- geniurg Off
- geninoc Off
- geniincon Off
- geniuri Off
- genidiap Off
- 16lowna Off
- genicyell Off
- genicamber Off
- genicbr0 Off
- genicbt Off
- genicother Off
- genicla Off
- geniclo Off
- genised Off
- geniodno Off
- genifol Off
- geniwitdif Off
- genisup Off
- geniyes Off
- genino Off
- 1620 Off
- 1615 Off
- 1630 Off
- 1630cosn Off
- 1630lBM Off
- 1630diar Off
- 1630rect Off
- 1630hemo Off
- 1630incon Off
- 1630diap Off
- 1630lax Off
- 1630w Off
- 1630d Off
- 1630m Off
- 1630lleost Off
- 1630pat Off
- 1630car Off
- 1630sn Off
- 1630ot Off
- 1630np Off
- 1630follow Off
- genblis Off
- genmass Off
- gencys Off
- genwart Off
- geninf Off
- gensurg Off
- genprost Off
- gensef Off
- genmeno Off
- genhyst Off
- gendisc Off
- geniodyes Off
- gennp Off
- 1630flat Off
- 17001 Off
- 17002 Off
- 17004 Off
- 1700head Off
- 1700perr Off
- 1700up Off
- 1700apha Off
- 1700rec Off
- 1700exp Off
- 1700mot Off
- 1700gro Off
- 1700dom Off
- 1700weak Off
- 1700trem Off
- 1700fine Off
- 1700gross Off
- 1700paral Off
- 1700stu Off
- 1700halluc Off
- 1700psy Off
- 1700oth Off
- 1700np Off
- EFAD TPN Off
- 17003 Off
- EFAD jej Off
- EFAD iv Off
- EFAD pum Off
- EFDA bol Off
- EFDA con Off
- EFA pat Off
- EFDA sn Off
- EFDA car Off
- EFDAoth Off
- EFDAfu Off
- EFDA na Off
- EFDA np Off
- abd pa Off
- ABD dis Off
- ABD hard Off
- ABD soft Off
- ABD asc Off
- ABD ab Off
- ABD oth Off
- ABD bow Off
- ABD other Off
- ABD ten Off
- EFAD Nas Off
- efad gas Off
- EFAD ot Off
- 17101 Off
- 17102 Off
- 17103 Off
- 17104 Off
- 17105 Off
- 17100 Off
- 1720 Off
- gen dis Off
- genbre Off
- genmast Off
- genoth Off
- 1700fin Off
- 1700mig Off
- genles Off
- 1630 other Off
- 1730 Off
- 1745 Off
- 1750 Off
- 17450 Off
- 1730a Off
- 1730b Off
- 17000 Off
- 17401 Off
- 17402 Off
- 17404 Off
- 17405 Off
- 17406 Off
- 17407 Off
- 1 Oriented Off
- msnp Off
- pslb Off
- psni Off
- psd Off
- psnas Off
- lbm Off
- lbps Off
- lbph Off
- lbf Off
- lbs Off
- urw Off
- sceri Off
- 17403 Off
- ps Off
- ABD pn Off
- pslm Off
- psdp Off
- pspl Off
- psrf Off
- psnh Off
- psue Off
- psir Off
- pse Off
- psep Off
- psea Off
- psvep Off
- psin Off
- psph Off
- psab Off
- psfin Off
- msor Off
- msfr Off
- msre Off
- msp Off
- mssw Off
- mscon Off
- msat Off
- msad Off
- mscan Off
- msuns Off
- mstp Off
- mswal Off
- msdec Off
- par Off
- msot Off
- mssh Off
- mswe Off
- mswea Off
- mskp Off
- msother Off
- mshe Off
- mspa Off
- msqua Off
- msoth Off
- msnop Off
- psina Off
- pssi Off
- psnap Off
- psinap Off
- psan Off
- psfat Off
- pswit Off
- psdif Off
- psdis Off
- psdep Off
- psanx Off
- psnp Off
- psade Off
- psdisc Off
- mscom Off
- msamp Off
- FL2 Off
- FL3 Off
- FL7 Off
- FL8 Off
- FL9 Off
- FLA-d Off
- FLb Off
- FLg Off
- FLart Off
- FLdiz Off
- FLhead Off
- FLins Off
- FLanx Off
- FLsob Off
- FLpoor Off
- FLprod Off
- FLheart Off
- FLp Off
- FLu Off
- FLv Off
- FLed Off
- FLc Off
- FLf Off
- FL1l Off
- FL1b Off
- FL1d Off
- FL1p Off
- FL1li Off
- FL1lr Off
- FL1lc Off
- FL1f Off
- FL1n Off
- FL4 Off
- FL6 Off
- FL5 Off
- adl o Off
- adl 1 Off
- adl 2 Off
- adl 3 Off
- 1810 0 Off
- 1810 1 Off
- 18102 Off
- 18103 Off
- 19100 Off
- 18200 Off
- 18201 Off
- 18202 Off
- 18203 Off
- FL1 Off
- 1910sg Off
- 1910sgp Off
- 1910sgd Off
- 1111910sgp Off
- 1910sgo Off
- 18302 Off
- 18301 Off
- 18300 Off
- 18304 Off
- 18305 Off
- 18306 Off
- 18400 Off
- 18401 Off
- 18402 Off
- 18403 Off
- 18404 Off
- 1910sgpat Off
- 18901 Off
- 18902 Off
- 18903 Off
- 18904 Off
- 18905 Off
- 1890na Off
- adlr Off
- adlna Off
- adlsn Off
- adlm Off
- adlp Off
- adlot Off
- adlst Off
- 18303 Off
- adlcom Off
- 1845 Off
- 1880 Off
- adl Off
- 1850 Off
- 1860 Off
- 1870 Off
- 1900a Off
- 1900b Off
- 1900d Off
- 1900c Off
- 18900 Off
- 19101 Off
- 19102 Off
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- 19104 Off
- 19105 Off
- 19106 Off
- 19107 Off
- 19108 Off
- 19109 Off
- 1910aw Off
- 1910bw Off
- 1910cnr Off
- 1910do Off
- alleasp Off
- alleggs Off
- alleib Off
- allesulf Off
- allead Off
- alledm Off
- allelod Off
- allepol Off
- alledust Off
- alleother Off
- 20000 Off
- 2000na Off
- 14D1 Off
- 20001 Off
- 20002 Off
- 2010 Off
- 2002 Off
- 2040a Off
- 2040b Off
- 2020 Off
- 2030 Off
- infpat Off
- picccir Off
- ivadacc Off
- int Off
- fo Off
- fa Off
- ule Off
- infiv Off
- perip Off
- mc Off
- gros Off
- tun Off
- nt Off
- ld Off
- lt Off
- cl Off
- pat Off
- rn Off
- cg Off
- ivocc Off
- ivflu Off
- res Off
- red Off
- allerno Off
- iv-i Off
- adp Off
- adc Off
- adrn Off
- adoth Off
- pia Off
- athe Off
- eiv Off
- biood Off
- mva Off
- pn Off
- infna Off
- infcare Off
- rldna Off
- 2100a Off
- 2100b Off
- 2100c Off
- 2100d Off
- 2100e Off
- 2100f Off
- 2100g Off
- 2110 Off
- asheb Off
- ashmet Off
- asehmop Off
- asprost Off
- asebed Off
- aseshow Off
- asescoot Off
- asehoist Off
- asegrab Off
- asehosp Off
- aselif Off
- asewhee Off
- aseoth Off
- aseneed Off
- aseoxy Off
- asefire Off
- aseph Off
- aseorg Off
- asena Off
- smlasa Off
- pump Off
- smcou Off
- smght Off
- smpup Off
- smrp Off
- smwd Off
- smal Off
- smpco Off
- smpfi Off
- smsa Off
- smpic Off
- smsp Off
- smtsc Off
- smsd Off
- smgip Off
- smgup Off
- smst Off
- smcc Off
- smpes Off
- smep Off
- smms Off
- smcp Off
- smcpat Off
- smcht Off
- smcfsh Off
- smpsbp Off
- smoth Off
- oxgava Off
- oxknosw Off
- prr Off
- shan Off
- adi Off
- epci Off
- apn Off
- cih Off
- pmi Off
- sphic Off
- acihsf Off
- dcdmi Off
- dnr Off
- sac Off
- opnc Off
- msr Off
- hsg Off
- asii Off
- gp Off
- fpp Off
- other Off
- pttv Off
- ottv Off
- sttv Off
- ottvist Off
- oxu Off
- oxupe Off
- oufsp Off
- sh Off
- ih Off
- hd Off
- fab Off
- ug Off
- ir Off
- us Off
- nta Off
- pp Off
- mss Off
- ep Off
- ev Off
- sb Off
- adce Off
- sf Off
- ppf Off
- rma Off
- hsd Off
- ppnf Off
- dfc Off
- fpi Off
- dim Off
- imm Off
- ipp Off
- put Off
- cp Off
- ph Off
- sn Off
- ot Off
- st Off
- aid Off
- oth Off
- mfc Off
- nch Off
- oo Off
- mmc Off
- idt Off
- sse Off
- sdi Off
- ncwdo Off
- ddt Off
- eo Off
- no so-cg Off
- nancg Off
- salin Off
- 2x2 Off
- 4x4 Off
- abd Off
- telf Off
- tap Off
- wg Off
- glov Off
- ns Off
- hyd Off
- ks Off
- td Off
- oint Off
- cs Off
- ther Off
- rb Off
- ic Off
- ivsk Off
- ivp Off
- ivt Off
- as Off
- asi Off
- per Off
- et Off
- cid Off
- ip Off
- ss Off
- duo Off
- bs Off
- abs Off
- m2x11 Off
- mt2 Off
- s4x4 Off
- ng Off
- und Off
- ec Off
- ub Off
- op Off
- ow Off
- sat Off
- fol Off
- ls Off
- sc Off
- tc Off
- aa Off
- otth Off
- app Off
- chem Off
- cta Off
- dcfg Off
- hyt Off
- it Off
- syr Off
- glu Off
- es Off
- ft Off
- srk Off
- strk Off
- sstri Off
- is Off
- stst Off
- ta Off
- vg Off
- kl Off
- sr Off
- bath Off
- can Off
- com Off
- smo Off
- prd Off
- egg Off
- hb Off
- hl Off
- efp Off
- neb Off
- oc Off
- pup Off
- pui Off
- or Off
- inj Off
- ivinf Off
- inh Off
- pcbp Off
- fcc Off
- pe Off
- wcd Off
- pai Off
- doc Off
- soa Off
- injr Off
- pt Off
- sup Off
- atu Off
- qc Off
- sd Off
- cht Off
- mep Off
- ncfa Off
- dpd Off
- wdc Off
- dmc Off
- iad Off
- gc Off
- nmd Off
- trc Off
- oca Off
- fc Off
- pfv Off
- oup Off
- uhm Off
- pmh Off
- eim Off
- e911 Off
- puitc Off
- cpdv Off
- dpdp Off
- rp Off
- ko Off
- ipai Off
- iop Off
- iudp Off
- dc Off
- ds Off
- spe Off
- sfcp Off
- ispm Off
- npp Off
- fi Off
- issi Off
- cqm Off
- idc Off
- msw Off
- iicm Off
- ign Off
- ret Off
- mrw Off
- pcd Off
- dccw Off
- ort Off
- epum Off
- meac Off
- pebp Off
- iap Off
- iiph Off
- iccs Off
- ipc Off
- icdb Off
- ipm Off
- ipap Off
- eiad Off
- ipaot Off
- odit Off
- mepc Off
- ttdp Off
- scwc Off
- mr Off
- dn Off
- cef Off
- pcm Off
- si Off
- spi Off
- eplan Off
- oa Off
- nmbs Off
- tg Off
- idp Off
- ipd Off
- icid Off
- igp Off
- ief Off
- ida Off
- nss Off
- api Off
- aps Off
- pst Off
- sib Off
- sdp Off
- ippph Off
- aperi Off
- pf Off
- ap Off
- apv Off
- pa Off
- ans Off
- imb Off
- imt Off
- ewl Off
- acb Off
- mlc Off
- eob Off
- afs Off
- paa Off
- rt Off
- das Off
- got Off
- lsm Off
- dpc Off
- ils Off
- mpb Off
- iao Off
- ihc Off
- mfs Off
- ipcp Off
- tae Off
- iua Off
- tsb Off
- pc Off
- hc Off
- sp Off
- mdc Off
- oh Off
- tpr Off
- ad Off
- awa Off
- psm Off
- gs Off
- wc Off
- lhk Off
- awpc Off
- errand Off
- nlb Off
- fnc Off
- pric Off
- rsf Off
- src Off
- ebc Off
- ppt Off
- gtwa Off
- ebp Off
- eem Off
- nme Off
- nsf Off
- bmt Off
- thm Off
- tt Off
- ism Off
- ephs Off
- irle Off
- isc Off
- atp Off
- mre Off
- te Off
- pas Off
- sfe Off
- pom Off
- sad Off
- isp Off
- fsm Off
- idy Off
- vdt Off
- ar Off
- noc Off
- ldt Off
- mfa Off
- crm Off
- crp Off
- lrp Off
- mrms Off
- sps Off
- acmr Off
- hwi Off
- hdic Off
- psn Off
- dsdc Off
- usb Off
- dcw Off
- saic Off
- dptw Off
- rsm Off
- kss Off
- uhc Off
- hpa Off
- ipi Off
- grp Off
- ftcm Off
- wac Off
- ria Off
- paf Off
- pafi Off
- pwe Off
- ptc Off
- ges Off
- otp Off
- pwdf Off
- pdaf Off
- pdi Off
- pdis Off
- phas Off
- pep Off
- 12100 Off
- allepen Off
- Patient is not diabetic or is bilateral amputee
- mswref Off
- genitonoprob Off
- Urostomy describe skin around stoma Off
- nutrinoprob Off
- O2prod Off
- woraft Off
- woreve Off
- wormor Off
- worsleep Off
- prodsputcol
- fname Off
- Rehabdc1 Off
- mswgwk1
- stgwk2
- stgwk1
- stgwk3
- rhpoor Off
- Clear Form
- E-mail Form
INFUSION IV THERAPY (Contd)
Infusion care provided during visitPump (type specify)OtherCaregiverPatient RNAdministered by
Purpose of Intravenous Access
Pain control
Lab drawsInterventions Instructions Comments Problems DetectedAntibiotic therapy
Maintain venous accessChemotherapyParenteral nutrition (TPN)HydrationOther
CARE MANAGEMENT
(M2100) Types and Sources of Assistance Determine the level of caregiver ability and willingness to provide assistance for the following activitiesif assistance is needed (Check only one box in each row)
Caregiver(s)Caregiver(s) Unclear ifNeed TrainingCaregiver(s) AssistanceNo Assistance Not Likely toCurrently Supportive Caregiver(s) Needed ButType of Assistance Needed in This Provide ProvideServices to Will Provide No Caregiver(s)Area Assistance AssistanceAssistance Provide Available
Assistance
a ADL Assistance (egtransferambulation bathingdressing toileting eatingfeeding)
0 1 2 3 4 5
b IADL Assistance (egmeals housekeepinglaundry telephone shoppingfinances)
0 1 2 3 4 5
c Medication Administration(eg oral inhaled orinjectable)
0 1 2 3 4 5
d Medical ProceduresTreatments (eg changingwound dressing)
0 1 2 3 4 5
e Management of Equipment(includes oxygen IVinfusionequipment enteralparenteralnutrition ventilator therapyequipment or supplies)
0 1 2 3 4 5
f Supervision and Safety(eg due to cognitiveimpairment)
0 1 2 3 4 5
g Advocacy or Facilitation ofpatients participation inappropriate medical care(includes transportation to orfrom appointments)
0 1 2 3 4 5
(M2110) How Often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)1 - At least daily 4 - Received but less than weekly
5 - No assistance received2 - Three or more times per weekUK - Unknown3 - One to two times per week
APPLIANCES SPECIAL EQUIPMENT HOME MEDICAL EQUIPMENT Co
Needs (specify)BraceOrthotics (specify)
Bedside commodeTransfer equipment BoardLift Oxygen HME Co
Prosthesis RUE RLE LUELLEOther HME Rep
Grab bars BathroomOther
PhoneOrganizations providing Home Medical Equipment (HME)
Hospital bed Semi-elec Crank SpecLifeline
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Patient Name Med Record
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Ostomy Pliers Shower chair Scooters Hoists
Wheeled Walker Other Phone NA
NA
Removing line date (if know)
Expand intravascular volume
Blood and its derivativesNA
NA
NA
(SOC)
SGFire PreventionSafety Program in place Patient instructed
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SAFETY MEASURES LIVING ARRANGEMENTS SUPPORTIVE ASSISTANCE
Oxygen use NYSigns postedYFollow smoking flammables safety precautions N
Oxygen back-up Knows Instructed how to useAvailable
Oxygen Precautions explained
PlanComments
Safety hazards in the home (check all that apply)NYFire alarmsmoke detector Fire extinguish
Inadequate heating cooling electricity lightingHurricane Disaster Emergency supplieskits
NY
InstructionsInformation Provided Sign Up package (Check all that apply)
Y N
Patient Rights and responsibilities
NYFirst aid boxEmergency Equipment or Supplies
State hotlineABUSE number
NYUnsafe gaselectrical appliances or electrical outlets
Advance directives information
NYInadequate running water plumbing problemsDo not resuscitate (DNR) (if applicable)NUnsafe storage of supplies equipment HME
No telephone available andor unable to use the phonePest problems InsectsrodentsMedications stored safely clearly-easy use check interactions
Service AgreementContractNYOASISHIPAA Privacy Notice ConfidentialityNY
Emergency Plan classification instructionsNYAgency phone numbers addressEmergency planning Exit Plan in place more than one exitClient Information Handbook
Y N
Standard precautions handwashing Infection Control
NYEnough Ventilation
Home safety guidelines
Safe BedsChairs clear pathways
Admission criteria Information for Home visit Services FrequencyY NAble to follow directions in case of Emergency
Diabetes Control other disease management informationNYSlippery Floors Ashtrays (if a smoker)
Fall Prevention Program
NYPlan for power failure emergency lights flashlights etc
THERAPY AND PLAN OF CARE(M2200) Therapy Need in the home health plan of care for the Medicarepayment episode for which this assessment will define a case mixgroup what is the indicated need for therapy visits (total of reasonableand necessary physical occupational and speech-language pathologyvisits combined) (Enter zero [000] if no therapy visits indicated)
) Number of therapy visits indicated (total of physicaloccupational and speech-language pathology combined)
(
NA - Not applicable No case mix group defined by this assessment(M2250) Plan of Care Synopsis (Check only one box in each row) Does the physician-ordered plan of care include the following
PlanIntervention YesNo Not Applicable
a Patient-specific parameters for notifying physician ofchanges in vital signs or other clinical findings 0 1 na
Physician has chosen not to establish patient-specific parameters for this patient Agency will usestandardized clinical guidelines accessible for allcare providers to reference
b Diabetic foot care including monitoring for the presence ofskin lesions on the lower extremities and patientcaregivereducation on proper foot care
0 1 naPatient is not diabetic or is bilateral amputee
c Falls prevention interventions 0 1 na Patient is not assessed to be at risk for falls
d Depression intervention(s) such as medication referral forother treatment or a monitoring plan for current treatment 0 1 na Patient has no diagnosis or symptoms of
depression
e Intervention(s) to monitor and mitigate pain 0 1 na No pain identified
f Intervention(s) to prevent pressure ulcers 0 1 na Patient is not assessed to be at risk for pressureulcers
g Pressure ulcer treatment based on principles of moistwound healing OR order for treatment based on moistwound healing has been requested from physician
0 1 naPatient has no pressure ulcers with need for moistwound healing
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Y
NY
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Patient Name Med Record
HOME ENVIRONMENT SAFETY
NYRelevant medical appliances if applicable ( wheelchair O2 Monitors etc)NYHurricane Shutter Disaster Plan
Medication sheet reconciliatedchecked
Alzheimers Sensory impairments info
Care Plans
Pain Management info Grievance Procedures
Local Resources Guide Mission ownership information
Physical Therapy Total visitsOccupational Therapy Total visits
Speech Therapy Total visitsOther Therapy Total visits
(SOC)
Safety Measures CMS485 (POC)
Cast PrecautionsChange position slowlyCoumadinHeparin PrecautionsDo not lift bend stoopGood handwashing techniqueOxygen PrecautionFire preventionPractice Universal Precautions
15
Safe Ambulation
Respiratory PrecautionsDiabetic PrecautionsWoundDecubitus precautionsAdequate lightingPrevent Cardiac OverloadPrevent Falls and Injuries GI Precautions
Prev Infection ComplicationsSeizure PrecautionsSuicide precautionsSupport due functional limitationTeach coping skillsSafe storagedisposal syringes Cardiac Precautions
GU Precautions
Safe TransfersSAN PrecautionsCatheter CareProvide Emotional SupportEmergency Plan
Maintain Safeclear EnvironmentMaintain Good Skin care
Clear pathways
Other
SG
Correct handwashing technique SG
Check bathroom floorstairs for safety hazardsPsycho-social behavior precautions
SG
SGSG
SG
SG
SG
Other
SG
SG
SG
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PATIENT CARE COORDINATION
CARE PLAN Reviewed with patient involvementOrder obtainedMedication Form completedreviewedupdated No changeMEDICATION RECORD
Ineffective drug therapySignificant drug interactions
Significant side effectsNon-compliance with drug orders Duplicate drug therapy
Other (specify)M S WSNPhysician AidePT OT STCARE COORDINATION
Explain
Yes No
DME SUPPLIES
IV start kit Underpads size BathbenchChemstrips2x2sIV pole
External catheters
Syringes Cane Quad CaneIV tubing
Urinary bagpouch
COTTON TIP APP4x4s
CommodeAlcohol swabs
Ostomy pouch (brand size)
Special mattress overlayABDs
Angiocatheter size
Cotton tipped applicatorsPeroxide Ostomy wafer (brand size)
Pressure relieving device
Wound cleanserExtension tubingsWound gel
Injection caps
Stoma adhesive tape
Eggcrate
Drain sponges Central line dressing
Skin protectant
Hospital bed
GlovesNon-sterile
Side Rails
Infusion pump Hoyer lift
Sterile Batteries size Enteral feeding pump
Hydrocolloids
Enema suppliesSyringes size
Nebulizer
Kerlix size
Feeding tubeNu-gauze
MEFIX 2X11 YD (EA)
Oxygen concentrator
sizetype Suction machine
SalineNSS
FOLEYCATH SUPPLIES
Suture removal kit Ventilator
Tape
Fr catheter kit
Staple removal kit Walker
(tray bag foley)Transparent dressings
Steri strips
Straight catheter
Wheelchair
Ointment
TRIPLE ANTIBIOTIC 30GR
Irrigation tray
Tens unitSalineNSS
OtherAcetic acid
Other
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Patient Name Med Record
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PATIENTCAREGIVER INSTRUCTIONS-TEACHINGCheck all that appliesPatientcaregiver(CG) independent with
Trach care
N oYesWoundDecubitus care
Yes No
Yes N o
Ostomy care Yes
N oYesDiabetic managementcare
N o
N oYesNoYesInsulin administration N oYes
Oxygen useprecautions
Yes N oGlucometer usecalibration N oYes
Use of home medical equipmentdevices
N oYesNutritional managementDiet
NoCaregiver present during the visit Yes
PatientCG educationteaching this visit for
N oYesPatientCG able to understand instructionsteaching
Does the patientCG have a plan when disease symptoms exacerbate (eg when to call the nurseAgency vs emergency 911) N oYes
Comment(s)
SKILLED CARE PROVIDED THIS VISIT
Medication management Administration Oral Injection IV-Infused Inhaled
Foley care Yes N o
Pain ManagementHome prescribed exercisesActivities of Daily LivingPersonal Care
MEDICATION
DISEASE PROCESS COMPLICATIONSSS OFILEAL CONDUITOSTOMY SKINFOOT CAREDIET FLUIDS INFECTION CONTROL
OTHER INSTRUCTIONS GIVEN
N oYesElimination Incontinence management
NEEDS FURTHER TEACHINGExplain
NA NANANANANA
NANANANANANANA
Yes N oPhysician follow up visitsappointments NA
Expected Outcome
DISCHARGE PLANNING DISCUSSEDEXPLAINED Patient unable to perform own Wound Care dueto
Patient unable to InsulineInjection self administration dueto
No SO or CG ablewilling for wound careInsulin-Injection administration at this time
Telfa
Colostomy Supplies
Thermometer
Texas Cath
Red Box (Biohazard)
Betadine Solution
Abd Pads
Duoderm
Sharp Container
Ace band size
Leg Straps Cath
ALCOHOL PREP PADS
DUODERM CFGHY-TAPE 2INSERTION TRAY 5CC
INSULIN SYRINGE ____ CCSYRINGES
Glucometer
MICROPORE TAPE 2
SOFTWICK 4X4
VASELINE GAUZE 3X9
KLING 4
(SOC)
Medication Management Check all that appliesidentified Potential adverse effectsdrug reactionsSG
Skil led Observation AssessmentINJECTION ROUTE_______ SITE _____ MED GIVEN ______________________ DOSE __________ REACTION _____________________________
Foley ChangeCare Patient Educationteaching Wound Care Dressing Change Prep Admin Insulin
StandardUniversal Precautions Followed Aseptic Tech Used Quality Control of Glucometer Performed Sharps Discarded Inside Sharps Container
ProcedureTx welltolerated by Pt
Diabetic Observation Care
Correct handwashing technique followed SG ManagementEvaluation Patients Care Plan No caregiverfamily availablewilling to help patient with care procedures
SG
Pshycological carebehaviour problems prevention NA
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Orders by discipline (optional) To complete CMS485 (POC)
SN - ORDERS - FREQUENCYDURATION
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Patient Name Med Record
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OTHER
General
Psychiatric
F o l e y Care
REPORT ANY ELEVATIONS IN TEMPERATURE TO THE MD
Wound CareDecubitus
IMPROVE THE PTS ABILITY TO PREVENT OR COPE WITH BREATHING DIFFICULTIES
Asthma Respiratory
INST FOR SS EASY FATIGABILITY DYSPNEA PALPITATIONS ANGINA TACHYCARDIAPALLOR DIZZINESS JAUNDICE AND FEVER INST FOR G I DISTURBANCES ASSESS FOR CENTRALNERVOUS SYSTEM SYMPTOMATOLOGY OBTAIN APPROPRIATE LAB TESTS AND REPORT FINDINGS TO MD ADMINISTER PRESCRIBED INJECTABLE _________________ USING ______ TECHNIQUE
Anemia
Included as reference only your Professional Staff must reviewupdatepersonalizedapprove the orders
INSTRUCT IN PREPARATION amp ADMINISTRATION OF INSULIN INSTRUCT ONSET PEAK ampDURATION OF ACTION OF INSULIN INSTRUCT PROPER DISPOSAL OF SYRINGESNEEDLES NURSE TO MONITOR BLOOD SUGAR WITH GLUCOMETER OR ___________ON __________FREQUENCY ampNOTIFY MD OF ALTERED RESULTS TEACH GLUCOMETER OR __________ PROCEDURE amp INTERPRETING RESULTS
InsulinGlucometer
INST DISEASE PROCESS amp COMMON COMPLICATIONS INST PRESCRIBED DIET amp SHOPPING ADVICE INST SSHYPOHYPERGLYCEMIA amp EMERGENCY PROCEDURES INST GOOD SKIN CARE amp GOOD FOOT CARE DAILY CARE OFTEETH INST DIABETIC CHART INST SampA TESTING amp READING RESULTS INSTRUCT TO CARRY ID THAT INCLUDESINFORMATION REGARDING DIABETIC STATUS NAMES amp DOSAGE OF MEDS amp ACTION TO TAKE IF INSULIN REACTION OCCURS INST IMPORTANCE OF GOOD PERSONAL HEALTH HABITS INCLUDING EXERCISE ADEQUATEREST SLEEP REGULAR MED CHECK-UPS (INCLUDING PODIATRIC OPTHAMOLOGIST amp DENTIST)
DiabetesMellitus
INST PACED ACTIVITY PROGRAM
OBSERVE FOR SS OF DECOMPENSATION SUCH AS INCREASING TACHYCARDIA WSUDDEN ONSET SOB ON MINEXERTION ORTHOPNEA EXTREME ANXIETY PROGRESSIVE CYANOSIS GENERALIZED PALLOR AND DIAPHORESISCHF
INSTRUCT PROPER ADMINISTRATION OF OXYGEN THERAPY INSTRUCT OXYGEN PRECAUTIONSINSTRUCT MAINTENANCE OXYGEN EQUIPMENTOxygen
ASSESS FOR CHEST PAIN TYPE LOCATION INTENSITY DURATION amp FREQUENCY IS PAINMANAGEMENT NOTIFY MD IF PAIN PERSISTS IS GRADUAL PROGRESS ACTIVITY INCREASEINST DISCONTINUE ACTIVITY IF CHEST PAIN DYSPNEA FATIGUE OR PALPITATIONS OCCUR
Angina
PSYCHOLOGICAL ASSESSMENT ASSESS NEUROLOGICAL STATUS IMPLEMENT AND MONITOR BOWEL REGIMEN ampTEACH PROGRAM TO FAMILY SN TO MONITOR TRANQUILIZER EFFECTS GIVEN FOR SEVERE AGITATIONANXIETYEVALUATE FOR WEIGHT LOSS WEIGH PATIENT Q VISIT AND RECORDS WEIGHTS MONITOR LEVEL OFCONSCIOUSNESS ASSESS COORDINATION AND BALANCE PROVIDE EMOTIONAL SUPPORT TO PATIENT ANDFAMILY OBSERVATION AND EVALUATION OF BLADDER ELIMINATION HABITS MANAGEMENT IF INCONTINENCEASSIST FAMILY IN SETTING UP ROUTINE PATIENT-CENTERED AND STRESS THE IMPORTANCE OF ADHERING
Alzheimers
AIDE - ORDERS - FREQUENCYDURATIONTUBSHOWER BATH PERSONAL CARE HAIR COMB SHAMPOO PRN MOUTHDENTURE CARE SKIN CHECK ORAL HYGIENE TPRASSIST TO DRESS ASSIST WITH AMBULATION PREPARE SERVE MEALS GROCERY SHOP WASH CLOTHES LIGHT HOUSEKEEPING ASSIST WITH PERSONAL CARE AND ADLSERRANDS NOTIFY LAST BM IF NONE FOR 3 DAYS FEETNAILS CARE PERI CARE REPORT SIGNIFICANT FINDING TO SN STRAIGHTEN ROOM amp CHANGE LINEN
PT - ORDERS - FREQUENCYDURATIONEVALUATE BALANCE AND COORDINATION EVALUATE ENDURANCE MOBILITY NEUROMUSCULAR RE-EDUCATIONPERFORM PRESCRIBED THERAPEUTIC EXERCISES NOTIFY SIGNIFICANT FINDING TO MDAGENCY BED MOBILITY TRAININGGAIT TRAINING WITH ASSISTIVE DEVICE TEACH HOME MAINTENANCE PROGRAM AND STRENGTHENING EXERCISEEXERCISE BOTH PASSIVE AND ACTIVE EXERCISE REGIMEN TRANSFER TRAINING INSTRUCT IN SAFETY MEASURES FALL PRECAUTIONS
OT - ORDERS - FREQUENCYDURATIONEVALUATE PATIENT AND HOME FOR SAFETY ADL TRAINING PROGRAM MUSCLE RE-EDUCATION BODY IMAGE TRAININGINCREASE RIGHT AND LEFT UPPER EXTREMITIES STRENGTH THERAPEUTIC EXERCISE TO (R) AND (L) HANDINCREASE STRENGTH AND COORDINATION PROPRIOCEPTION AND SENSATION
ST FOR EVALUATION TO PROVIDE ORAL MOTOR EXERCISES INVOLVING LINGUAL AND LABIAL EXERCISES SPEECH ARTICULATION DISORDER TREATMENTIMPROVE SPEECH FACIAL SYMMETRY AND MUSCULATION IMPROVE DYSPHAGIA VOICE DISORDER TREATMENT AURAL REHABILITATION NON-ORAL COMMUNICATION LANGUAGE DISORDER TREATMENT
ST - ORDERS - FREQUENCYDURATION
MSW - ORDERS - FREQUENCYDURATIONMSW FOR ASSESSMENT OF SOCIAL AND EMOTIONAL FACTORS COMMUNITY RESOURCE PLANNINGCOUNSELING REGARDING MANAGEMENTADJUSTMENT TO ILLNESS LONG RANGE PLANNING AND DECISION MAKING
PROVIDE SUPPORTIVE AND RELAXATION THERAPY PROVIDE FAMILY THERAPY ASSESS INTERPERSONALBEHAVIOR ASSIST PATIENT TO DEFINE PROBLEMS amp SOCIAL RELATIONSHIPS GIVE POSITIVE REINFORCEMENTASSIST PATIENT TO VERBALIZE FEELINGS
Anxie ty
INST DISEASE PROCESS AND COMMON COMPLICATIONS INST LOW SODIUM DIET - STRESSING IMPORTANCE OFADHERENCE MONITOR PATIENTS BLOOD PRESSURE CLOSELY AND NOTIFY MD OF ANY SIGNIFICANT CHANGESINSTRUCT PT TO AVOID OVER-THE-COUNTER COLD AND SINUS MEDS AS THEY CONTAIN VASOCONSTRICTORINST OF HYPERTENSIVE CRISIS MONITOR FOR SS OF ORTHOSTATIC HYPOTENSION
Hypertension
ASSESS PSYCHOLOGICAL STATUS PROVIDE SUPPORTIVE THERAPY PROVIDE REMOTIVATION ASSESSINTERPERSONAL BEHAVIOR ASSIST PATIENT TO DEFINE PROBLEMS amp SOCIAL RELATIONSHIPS GIVE POSITIVEREINFORCEMENT ENCOURAGE PATIENT TO PERFORM PERSONAL HYGIENE amp GROOMING ACTIVITIESASSIST PATIENT TO EXPRESS REALISTIC IDEAS amp PLANS ASSIST PATIENT TO VERBALIZE FEELINGS
Depression
INSTRUCT PATIENT IN CONSEQUENT PHYSICAL L IMITATIONS PLANNING AN ADEQUATE LEVEL OF DAILYACTIVITIES TEACH PT RE ARTHRITIS SS OF EXACERBATION TEACH THE IMPORTANCE OF GOOD POSTUREPREVENT TRAUMA TO JOINTS INST PT IN THE USE OF ASSISTIVE DEVICE AS PRESCRIBED
Osteoarthritis
SKILLED OBSERVATIONEVALUATION ASSESS VITAL SINGS amp SS COMPLICATIONSINSTRUCTEVALUATE UNDERSTANDING OF DISEASE PROCESS DETECTING COMPLICATIONSDIETNUTRITIONAL STATUS SAFETY PRECAUTIONEMERGENCY MEASURES MED-REGIMEN
PSYCH ASSESSMENT ASSESS FOR SS OF EPSDETECT AND ALLEVIATE SOMATIZED COMPLAINTSLIMIT SETTING MOTIVATION TECHNIQUES IMAGERY TECHNIQUES
RELAXATION TECHNIQUESGOAL ORIENTED TASKS
FOLEY INSERTION _______FR FOLEY WITH___________cc BALLONCHANGE Q MONTH amp PRN x3 FOR CLOGGED LEAKING OR ACCIDENTAL REMOVALINST DRESSING CHANGES ________________________ MONITOR FOR SS COMPLICATIONS amp NOTIFY MD
INST SS INFECTION
MONITOR STATUS OF WOUND OR DECUBITUS (place) ______________INST INFECTION CONTROL MEASURES
INST GOOD NUTRITION TO FACILITATE HEALINGMEASURE AND RECORD WOUND or DECUBITUS SIZE AT SOC AND AT LEAST WEEKLY THEREAFTEROPEN WOUND CAREDRESSING CLEANSE WOUND WITH ___________ TO RINSE WITH __________ AND APPLY______________ AND PRN
OBSERVE AND RECORD TYPE AND AMOUNT OF DRAINAGE COLOR INFECTION SWELLING REDNESS PAINDE CUB ITUS CAR EDR ESS ING CLEAN SE W OUN D WITH ___________ TO R IN SE WITH __________ AN D APP LY ______________ AN D PR N
TEACH THE PATIENT HOW TO USE A METERED-DOSE INHALER MAINTAIN EFFECTIVE AIRWAY CLEARANCE
EMPHASIZE THE IMPORTANCE OF ADEQUATE DAILY FLUID INTAKE
PROMOTE AN EFFICIENT BREATHING PATTER
INST INFECTION CONTROL amp PULMONARY HYGIENE INST COMPLICATIONS IN CARDIOPULMONARY STATUSINST PREVENTION OF COMPLICATIONS IE AVOID OVER-EXERTION CHILLING CROWDS ETC
INST D ISEASE PROCESS amp MAINTENANCE
INSTRUCT COUGHING DEEP BREATHING EXERCISES INST PATIENT TO MAINTAIN ADEQUATE REST PATTERN
MANAGEMENT AND EVALUATION OF A PATIENT CARE PLAN TEACHING AND TRAINING DISEASE PROCESS SKIN CARE WOUND CAREDRESSING CHANGE DECUBITUS CARE MEDICATION REGIMEN DIETNUTRITIONHYDRATION COMPLICATIONS OF ENT FEEDING AS INDICATED
PAIN CONTROL MEASURES SYMPTOM CONTROL MEASURES SINGSSYMPTOMS OF INFECTION SAFETYPREVENTION OF INJURY EMERGENCY PLANS OXYGEN ADMINISTRATION
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GOALSREHABILITATION POTENTIAL CMS485 (POC)Included as reference only your Professional Staff must reviewupdatepersonalizeapprove the goals
DISCHARGE PLANNING DISCUSSED WITH PATIENT Yes No REHAB POTENTIAL ExcellentPoor Fair Good
SIGNATUREDATES
X DateStaff Completing the OASIS (signaturetitle)
OASIS INFORMATION
Data Entry Date amp Locked Date SubmittedQA Date Reviewed
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SN - GOALSMRMS _________________ WILL EXHIBIT VITAL SIGNS WITHIN ACCEPTABLE RANGE AND STABILIZED DISEASE PROCESSVERBALIZES KNOWLEDGE OF DISEASE MANAGEMENT MEDICATIONS SIDE EFFECTS PRECAUTIONS DIET FLUIDS TREATMENT PROGRAM SS NECESSITATING MEDICAL ATTENTION EMERGENCY CARE
STABILIZATION OF PSYCHOLOGICAL STATUS WITHIN DISEASE LIMITS TO REDUCE THE PATIENTS ANXIETY LEVELDEPRESIONANXIETY CONTROLED TROUGH MED REGIMEN INTERVENTIONS
ANEMIA CONTROLLED THROUGH MED REGIMEN IMPROVED HEMATOLOGIC STATUS
General
Psychiatric
A n e m i aHEALED WOUND WITHOUT INFECTION OR COMPLICATIONS DEMONSTRATE PROPER WOUND CARE
Wound Care
PTSO SHOULD UNDERSTAND THE NATURE SYMPTOMS STAGE AND PROGRESSION OF ALZHEIMERS DISEASEKNOW HOW TO RECOGNIZE PTS OWN STRESS AND WAYS TO PREVENT OR REDUCE IT PROMOTE SOCIAL INTERACTION AS TOLERATED BY THE PATIENT
Decubitus
DEMONSTRATE STRATEGIES TO BE USED DURING A COUGHING EPISODE HELP THE PATIENT IDENTIFY FACTORSTHAT MAY CAUSE ASTHMA ATTACKS OR CONTRIBUTE TO THEMAsthma
SAFELY ADMINISTERS INJECTION COMPREHEND RATIONALE FOR AND IS ABLE TO ROTATE INJECTION SITESCOMPREHEND SAFETY FACTORS IN SYRINGENEEDLE DISPOSALPATIENTCG ABLE TO MONITOR BLOOD SUGAR CORRECTLY WITHOUT ASSISTANCEABLE TO NOTIFY MD OF ALTEREDOUT OF RANGE RESULTS
InsulinGlucometer
DISCHARGE PT WHEN BLOOD SUGARS ARE WITHIN THE NORMAL FOR PATIENT RANGEKNOW THE ACCEPTABLE RANGE FOR BLOOD SUGAR LEVEL COMPLY WITH DIET RESTRICTIONS Diabetes
MellitusRETURN TO SELF-MANAGEMENT OF HEALED FRACTURED
FractureKNOW ABOUT SIGNS SYMPTOMS AND PRECIPITATING CAUSES OF CHF KNOW HOW TO TAKE THE PULSE AND KNOWTO CONSULT THE DOCTOR BEFORE CONTINUING MEDICATION IF THE PULSE RHYTHM CHANGES KNOW TOA V O I D S M O K I N G A N D S M O K Y E N V I R O N M E N T S A N D P E R S O N S W I T H I N F E C T I O N S E S P E C I A L L Y R E S P I R A T O R Y I N F E C T I O N S
CHF
UNDERSTAND THAT HYPERTENSION IS A CHRONIC DISEASE REQUIRING LIFE LONG TREATMENT EXHIBIT BLOODPRESSURE READINGS CONSISTENTLY WITHIN NORMAL OR SPECIFIED RANGE DEMONSTRATE ADHERENCE TO ALOW-SALT LOW-FAT DIET
Hypertension
HELP THE PATIENT ACHIEVE PAIN RELIEVE AND REDUCE ANGINA EPISODES UNDERSTAND THE CAUSE OFANGINA PECTORIS AND POSSIBLE PRECIPITATING FACTORS FOR AN ATTACK IDENTIFY PERSONAL STRESSORSTHAT MAY CONTRIBUTE TO THE PROBLEM AND BEGIN ELIMINATING OR MINIMIZING THEM KNOW WAYS TOREDUCE THE FREQUENCY OF ANGINA EPISODES
Angina
HEALED DECUBITUS WITHOUT INFECTION OR COMPLICATIONS DEMONSTRATE PROPER DECUBITUS CARE
Alzheimers
UNDERSTAND SS OF BRONCHITIS OR OTHER RESPIRATORY INFECTION AND DISEASE EXACERBATIONUNDERSTAND THE DANGERS OF SMOKING AIR AND CHEMICAL POLLUTANTS AND RESPIRATORY INFECTIONUNDERSTAND AND PRACTICE COUGHING AND DEEP-BREATHING EXERCISES
Respiratory
DAILY COMPLIANCE WCATHETER CARE DECREASE RISK OF URINARY INFECTIONCatheter
INCREASED PAIN RELIEF INCREASED STRENGTH AND ENDURANCE COMPREHEND AND DEMONSTRATE HOME EXERCISEOsteoarthritis
AIDE - GOALS
GAIT PATTERN ENDURANCE STRENGTH AND BALANCE WILL IMPROVE AND PATIENT WILL DEMONSTRATECORRECT BODY MECHANICS WIN 4-6 WKS PTCG WILL COMPREHEND AND DEMONSTRATE HOME EXERCISEPROGRAM WITHIN 4-6 WKS
FAIR-TO BE ABLE TO CARRY OUT MINIMAL ADLS WITH AVAILABLE HOME SUPPORTWILL NOT BE ABLE TO CARRY OUT ADLS WITHOUT MAXIMUM SUPPORT
RETURN TO INDEPENDENT AMBULATION BE SAFE IN SELF CAREPATIENT WILL BE ABLE TO FUNCTION WITH ASSISTANCE OF CAREGIVERWITHIN HESHE CURRENT LIMITATIONS AT HOME
PATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HISHER CURRENT LIMITATIONS AT HOME
PT - GOALS
GOOD RETURN TO PREVIOUS LEVEL OF ADLS INDEPENDENTLY
GAIT PATTERN ENDURANCE STRENGTH AND BALANCE WILL IMPROVE AND PT WILL DEMONSTRATECORRECT BODY MECHANICS WITHIN _____ WEEKS
PATIENT WILL EXPERIENCE A DECREASE IN PAIN
PTCG WILL COMPREHEND AND DEMONSTRATE HOME EXERCISEPROGRAM WITHIN _____ WEEKS
OT PATIENT WILL EXHIBIT IMPROVEMENT IN COPING IN ADLSIADLS MUSCLE USEMOTORCOORDINATIONNEURO RESPONSEUSE OF ORTHOTIC SPLINTING ANDOR EQUIPMENT
OT - GOALS
PATIENT WILL DEMONSTRATE FUNCTIONAL COMMUNICATIONS EXHIBIT MAXIMUM VERBAL AND SENTENCEFORMULATION AND COMPREHENSION WITHIN DISEASE LIMITS WITHIN _____ WEEKS
ST - GOALS
PATIENT WILL DEMONSTRATE APPROPRIATE USE OF FUNCTIONAL VERBALNON-VERBALCOMMUNICATIONS SYSTEMS WITHIN _____ WEEKS
PATIENT WILL DEMONSTRATE IMPROVED READINGWRITING USE OF GESTURESNUMBERS WITHIN _____ WEEKS
PATIENT WILL DEMONSTRATE IMPROVED SWALLOWINGCHEWINGORALMOTOR CONTROL WITHIN _____ WEEKS
PATIENT WILL HAVE ADEQUATE SUPPORT TO REMAIN IN HOME WITH ASSISTANCE OF COMMUNITYRESOURCES FOR FINANCIAL TRANSPORTATION AND PERSONAL CARE ASSISTANCE WITHIN _____ WEEKS
MSW - GOALSPSYCHOSOCIAL EVALUATION WILL BE PERFORMED PTCG WILL BE COUNSELED REGARDING MANAGEMENTamp ADJUSTMENT TO ILLNESS LONG TERM PLANNING AND DECISION MAKING APPROPRIATE COMMUNITYRESOURCE REFERRALS WILL BE MADE
WILL DISCHARGE THE PATIENT WITHIN 60 DAYS WHEN PATIENT ANDORCAREGIVER ISARE ABLE TO DEMONSTRATE KNOWLEDGE OF DISEASE MANAGEMENT SS COMPLICATIONSPATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HISHER CURRENT LIMITATION AT HOME
ABLE TO REMAIN IN HOMERESIDENCEALF WITH ASSISTANCE OF PRIMARY CAEGIVERSUPPORT AT HOMEABLE TO UNDERSTAND MEDICATION REGIMEN AND CARE RELATED TO HISHER DISEASEWILL BE DISCHARGE WHEN MAXIMUM FUNCTIONAL POTENTIAL REACHED
Patient Name Med Record
wwwpnsystemcom 3058185940 The Outcome and Assessment Information Set (OASIS) is the intellectual property of the Center for Health Services and Policy Research Denver Colorado It is used with permission Expiration date 7312012
XPatient Signature if required optional if itinerary is used
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- OASIS_C_SOC
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- PT ID PERFORMED VIA NAME DOB FACE RECOGNITION AND ADDRESS BEFORE SERVICE PROVIDED Off
- TIME IN
- TIME OUT
- Agency Name SALUD HOME CARE INC
- Phone 305-555-5555
- Employees NameTitle Completing the OASIS
- who has signed the plan of care
- Physician name
- Address 1
- Address 2
- Phone Number
- Address 1_2
- Address 2_2
- Patient Phone
- Reason
- Name
- Other Physician if any
- Phone_2
- Address 1_3
- Address 2_3
- Phone Number_2
- REFERRAL SOURCE if not from Primary Physician
- undefined_6
- Phone_3
- Fax
- Evacuation Form needed Emergency Reg 1
- Evacuation Form needed Emergency Reg 2
- EMERGENCY CONTACT
- Address
- Comments 1
- Comments 2
- Phone_4
- Relationship
- OTHER
- Comment 1
- Comment 2
- 11 Other specify
- a
- b
- 7 Other specify
- c
- d
- e
- f
- a_2
- b_2
- d_2
- e_2
- f_2
- a_3
- b_3
- d_3
- Comment if needed 1
- Comment if needed 2
- a_4
- a_5
- a_6
- Date 23
- undefined_7
- undefined_8
- b_4
- b_5
- b_6
- Date_2
- undefined_9
- undefined_10
- Date_3
- undefined_11
- undefined_12
- d_4
- d_5
- d_6
- Date_4
- undefined_13
- undefined_14
- Date_5
- undefined_15
- undefined_16
- Date_6
- undefined_17
- undefined_18
- 12 1
- 12 2
- Date_7
- undefined_19
- undefined_20
- Date_8
- undefined_21
- undefined_22
- MAIN REASON FOR HOME HEALTH CARE 1
- MAIN REASON FOR HOME HEALTH CARE 2
- Fractures site
- Surgeries site
- Cancer site
- Open Wound site
- Decubitus site
- Other specify
- Other
- Pending or Needed
- Yes Number of times
- Reason s Dates
- MobilityAmbulatory devices used
- Other specify_2
- undefined_23
- Comments if needed 1
- Comments if needed 2
- Comments if needed 3
- Comments if needed 4
- undefined_24
- Name_2
- Phone number if different from patient
- Relationshiphealth statusability to help 2
- Any paid help explain
- Specify 1
- Specify 2
- Specify 3
- Any ears surgeryprocedure
- Date_9
- Otherspecify 1
- Otherspecify 2
- Other agencies involved in care 1
- Other agencies involved in care 2
- 1
- 2
- Other_2
- Infections
- Cataract surgery Site
- Date_10
- Other eyes surgery Site
- Date_11
- explain 1
- explain 2
- Any nose surgery
- Date_12
- Other specify_3
- 1_2
- 2_2
- MassesTumors site
- Lesions explain
- Any surgeryprocedure
- Other specify 1
- Other specify 2
- Other specify 3
- Date_13
- Other specify_4
- No Problem
- Medication
- Other_3
- Pain control treatmentmeds Side effect mark
- Other_4
- Is there a regular pattern to the pain explain
- Other_5
- Comment
- What was the outcome
- Type II OnsetExacerbation date
- DietOral control specify
- INSULIN dosage frequency scale explain
- 1_3
- 2_3
- Since
- Other_6
- A1c
- BS
- mgdL DateTime
- Blood sugar ranges
- site 1Location site
- site 2Location site
- site 3Location site
- Frequency
- Other_7
- site 1New Onset Exacerbation
- site 2New Onset Exacerbation
- site 3New Onset Exacerbation
- Able to use Glucometer
- site 1Present level 010
- site 2Present level 010
- site 3Present level 010
- Diabetes Management Problems explain 1
- Diabetes Management Problems explain 2
- Other Endocrine problems
- site 1Occasional y Cont Intermittent Frequency Frequently
- site 2Occasional y Cont Intermittent Frequency Frequently
- site 3Occasional y Cont Intermittent Frequency Frequently
- site 1Pain type ach ng burn ng rad ating neura gia etc
- site 2Pain type ach ng burn ng rad ating neura gia etc
- site 3Pain type ach ng burn ng rad ating neura gia etc
- Anemia specify type if known
- site 1Feeling of pain internal external acute chronic
- site 2Feeling of pain internal external acute chronic
- site 3Feeling of pain internal external acute chronic
- site 1Pain is worse morning
- site 2Pain is worse morning
- site 3Pain is worse morning
- Immunodeficiency problems explain
- Other 1
- Other 2
- Other_8
- explain 1_2
- explain 2_2
- explain 3
- explain 4
- Other specify 1_2
- Other specify 2_2
- undefined_25
- undefined_26
- undefined_27
- undefined_28
- undefined_29
- undefined_30
- undefined_31
- undefined_32
- undefined_33
- undefined_34
- undefined_35
- undefined_36
- M1310 Pressure Ulcer Length Longest length headtotoe
- undefined_37
- cm
- greatest width perpendicular to the length
- M1314 Pressure Ulcer Depth Depth of the same pressure ulcer from
- cm_2
- visible surface to the deepest area
- undefined_38
- cm_3
- 1_4
- 2_4
- 3_2
- Other_9
- 4_2
- Caregiver name
- Other_10
- cant integument findings
- Observation
- Observation_2
- Caregiver name_2
- Other_11
- Wound cleaned with specify
- Wound irrigated with specify
- 1 Size
- cm width
- Wound packed with specify
- Location
- Other_12
- Wound dressingcover applied specify
- 2 Size
- cm width_2
- Comments 1_2
- Comments 2_2
- Location_2
- Other_13
- Sizecm LengthxWidthxDepth
- Sizecm LengthxWidthxDepth_2
- Diagram 4Sizecm LengthxWidthxDepth
- Tunneling Undermining cm
- Tunneling Undermining cm_2
- Diagram 4Tunneling Undermining cm
- Stage IIIIIIIV pressure uIcers only
- Diagram 4Stage IIIIIIIV pressure uIcers only
- Odor Fool normal etc
- Diagram 4Odor Fool normal etc
- Edema pedal sacral p tting etc
- Diagram 4Edema pedal sacral p tting etc
- Appearance of the Wound Bed
- Diagram 4Appearance of the Wound Bed
- Treatment Ordered
- Diagram 4Treatment Ordered
- Other_14
- Other_15
- Other_16
- Other_17
- Yes 1
- Yes 2
- Yes 3
- Height
- Weight
- Radiating to
- GainLoss
- lb X
- Frequencyduration
- Sittinglying R
- L
- Standing R
- L_2
- Medication_2
- Temperature
- Other_18
- Apical
- Brachial
- Radial
- Carotid
- Dependent
- Pitting 1234
- Respirations
- Site
- Cramps site
- Disease Management Problems explain
- Right Upper
- Right
- Right Lower
- 1_5
- 2_6
- 3_3
- Left
- Left Upper
- Left Lower
- Pacemaker Date
- Last date checked
- SOB on minimal effortwalk
- Type
- fy
- Other Prob 1
- Other Prob 2
- O2
- Trach sizetype
- CaregiverfamilyOther
- Yes explain 1
- Yes explain 2
- Other_19
- Comments 1_3
- Comments 2_3
- Increase fluids
- Restrict fluids
- Frequency_2
- Amount
- Yes describe 1
- Yes describe 2
- Frequency_3
- Other 1_2
- Other 2_2
- Nocturia x
- Bowel Off
- undefined_52
- Diapersother
- Other_20
- No
- 2TOTAL
- Urinary Catheter Type
- Last changed on
- Foley inserted date
- with
- Inflated balloon with
- Irrigation solution Type specify
- Amount_2
- mL Frequency
- Returns
- No_2
- 1_6
- 2_7
- Describe at risk intervention and plan 1
- Describe at risk intervention and plan 2
- Describe at risk intervention and plan 3
- DischargeDrainage describe
- Lesions
- Blisters
- Masses
- Cysts
- Wart
- Other specify_5
- Surgical alteration
- Prostate problem BPH TURP Date
- undefined_53
- undefined_54
- Selftesticular exam Frequency
- Hysterectomy Date
- undefined_55
- undefined_56
- Date last PAP
- undefined_57
- undefined_58
- Results
- Breast selfexam frequency
- Mastectomy R L Date
- undefined_59
- undefined_60
- Other specify_6
- Last BM
- Diarrhea Frequency
- Bowel regimeprogram
- Incontinence Off
- Urinary Off
- Diapersother_2
- Other_21
- te describe skin around stoma
- Ileostomycolostomy s 2
- Ileostomycolostomy s 3
- Ileostomycolostomy s 4
- Ileostomycolostomy s 5
- Headache Location
- Frequency_4
- Other_22
- Migraine Frequency
- Site_2
- Weakness UE LE Location
- Other specify_7
- Site_3
- IV
- Pump typespecify
- Hand grips Equal Unequal specify
- Feedings Type amtrate
- Strong Weak specify
- Psychotropic drug use specify
- Flush Protocol amtspecify
- DoseFrequency
- Other_23
- Other specify 1_3
- Other specify 2_3
- DressingSite care specify 1
- DressingSite care specify 2
- Interventions instructionsComments 1
- Interventions instructionsComments 2
- Following Un
- versalStandard precautions
- NA
- No Problem_2
- Pain Frequency
- Abdominal girth
- Bowel sounds active absent hypo hyperactive x
- 3 Forgetful Off
- 4 Depressed Off
- 6 Lethargic Off
- 5 Disoriented Off
- 7 Agitated Off
- 2 Comatose
- 8 Other Off
- Forgetful at times Off
- Irritable Off
- Anxious Off
- Alert Off
- Describe 1
- Describe 2
- undefined_61
- Needs interpreter
- Comments 1_4
- Comments 2_4
- Higher Educational Level
- Fracture location
- Swollen painful joints specify
- Explain
- Contractures Joint
- Spiritual resource
- Location_3
- Phone No
- Atrophy
- Other_27
- Explain 1
- Explain 2
- Decreased ROM
- Paresthesia
- Weakness
- Other_28
- Inappropriate followthrough in past
- Amputation BKAKUE RL specify 1
- Amputation BKAKUE RL specify 3
- Amputation BKAKUE RL specify 4
- Treatment
- Treatment_2
- Other specify 1_4
- Other specify 2_4
- History of Falls past 3 months 12 falls M1032
- V s on Status Poor w or w o glasses M1200
- Vision Status Poor Legally blind M1200
- Gait and Balance Balance problem while standing
- Gait and Ba ance Balance problem while walking
- Gait and Balance Decreased muscular coordination
- Pred spos ng D seases 12 present
- Predisposing D seases 3 or more present
- Equipment Issues Oxygen tubing
- 1Row1
- PlanComments 1
- PlanComments 2
- Comment_2
- undefined_62
- b Ambulation
- c Transfer
- DOther specify
- 7Independent in home 1
- 7Independent in home 2
- Other 1_3
- Other 2_3
- Typebrand
- Size
- Gauge
- Length
- Insertion site
- Insertion date
- Flush solution
- Frequency_5
- Injection cap change frequency
- Dressing change frequency
- Other_29
- Siteskin condition
- External catheter length
- OtherComment
- fluid overload Other
- Circumference of arm
- Huber gaugelength
- Yes date
- Last flushed date
- Siteskin condition_2
- Infusion solution typevolumerate
- Dressing
- OtherComment 1
- OtherComment 2
- Drug Name
- Dose
- Route
- Frequency_6
- Duration of therapy
- Drug Name_2
- Dose_2
- Route_2
- Frequency_7
- Duration of therapy_2
- CommentPlan 1
- CommentPlan 2
- Pump type specify
- Other_30
- Lab draws
- Infusion care provided during visit 1
- Infusion care provided during visit 2
- Infusion care provided during visit 3
- Antibiotic therapy
- 1_7
- 2_8
- Other_31
- Removing line date if know
- BraceOrthotics specify 1
- BraceOrthotics specify 2
- BraceOrthotics specify 3
- Needs specify 1
- Needs specify 2
- Oxygen HME Co
- Prosthesis RUE RLE LUELLEOther
- HME Rep
- Grab bars BathroomOther
- Hospital bed Semielec Crank Spec
- Other_32
- NA_2
- Phone_5
- n care
- PlanComments
- N
- Other_33
- undefined_63
- Physical Therapy Total visits
- Speech Therapy Total visits
- visits
- Other Therapy Total visits
- Patient is not assessed to be at risk for falls
- No pain identified
- Patient has no pressure ulcers with need for moist wound healing
- O
- Noncompliance with drug orders
- Expected Outcome
- Patient unable to perform own Wound Care due
- Pat
- to
- Abd Pads Off
- Underpads size
- undefined_68
- Special mattress overlay
- Angiocatheter size
- Ostomy pouch brand size
- Pressure relieving device
- Ostomy wafer brand size
- undefined_69
- SYRINGES
- Batteries size
- Skin protectant
- Glucometer
- Hydrocolloids
- undefined_70
- FOLEYCATH SUPPLIES
- Syringes size
- size
- Oxygen concentrator
- Feeding tube
- Ointment
- Acetic acid
- Other 1_4
- Other 2_4
- Other 3
- Tens unit
- KLING 4
- Other 1_5
- Other 2_5
- Other 3_2
- PatientCG educationteaching this visit for
- MEDICATION Off
- DISEASE PROCESS COMPLICATIONS Off
- undefined_71
- SS OF Off
- ILEAL CONDUITOSTOMY Off
- DIET FLUIDS Off
- undefined_72
- undefined_73
- SKINFOOT CARE Off
- INFECTION CONTROL Off
- OTHER INSTRUCTIONS GIVEN
- Caregiver present during the visit
- NEEDS FURTHER TEACHING Off
- No_3
- Skilled Observation Assessment
- ent Educat
- Wound Care Dress
- Diabetic Observation Care
- Correct handwashing technique followed SG 1
- Correct handwashing technique followed SG 2
- Correct handwashing technique followed SG 3
- Correct handwashing technique followed SG 4
- 21 Included as reference only your Professional Staff must reviewupdatepersonalizedapprove the orders
- SN ORDERS FREQUENCYDURATION
- S COMPLICATIONS
- TH GLUCOMETER OR
- ON
- TEACH GLUCOMETER OR
- NSERTION
- TH
- INST DRESSING CHANGES
- MONITOR STATUS OF WOUND OR DECUBITUS place
- ADMINISTER PRESCRIBED INJECTABLE
- USING
- TH_2
- TH_3
- AND APPLY
- CLEANSE WOUND WITH
- NSE WITH
- AND APPLY_2
- OTHER_2
- DE ORDERS FREQUENCYDURATION
- PT ORDERS FREQUENCYDURATION
- OT ORDERS FREQUENCYDURATION
- ST ORDERS FREQUENCYDURATION
- MSW ORDERS FREQUENCYDURATION
- Included as reference only your Professional Staff must reviewupdatepersonalizeapprove the goals 22
- MRMS
- PROGRAM WITHIN
- CORRECT BODY MECHANICS WITHIN
- COMMUNICATIONS SYSTEMS WITHIN
- undefined_75
- undefined_76
- Date_14
- QA Date Reviewed
- undefined_77
- undefined_78
- Data Entry Date Locked
- undefined_79
- undefined_80
- Date Submitted
- undefined_81
- undefined_82
- SOCD
- SOCM
- SOCY
- SOCM1
- SOCD1
- SOCY1
- Check Box2 Off
- Check Box3 Off
- Check Box4 Off
- TOM
- TOD
- TOY
- FDM
- FDD
- FDY
- Prov 1071523
- BrID
- Check Box9 Yes
- BrIDno
- Check Box11 Off
- DLCM
- DLCD
- DLCY
- LVM
- LVD
- LVY
- DNR1 Off
- Check Box19 Off
- STFL
- PZC
- MCN
- NOMC Off
- SSN1
- SSN2
- SSN3
- SSUK Off
- MAN
- MAUK Off
- DOBM
- DOBD
- DOBY
- SEX Off
- MR
- First
- MI
- Last
- Suffix
- RACE2 Off
- RACE3 Off
- RACE4 Off
- RACE5 Off
- RACE1 Off
- RACE6 Off
- PS3 Off
- PS0 Off
- PS1 Off
- PS4 Off
- PS5 Off
- PS6 Off
- PS7 Off
- PS8 Off
- PS9 Off
- PS10 Off
- PS11 Off
- PS2 Off
- PSUK Off
- Ecode
- COMP Off
- DACM
- DACD
- DACY
- REA Off
- DM
- DD
- DY
- RDM
- RDD
- RDY
- REFDM
- REFDD
- REFDY
- EPT Off
- 14D2 Off
- 14D3 Off
- 14D4 Off
- 14D5 Off
- 14D6 Off
- 14D7 Off
- 14D8 Off
- Check Box39 Off
- icd9c
- icd9a
- icd9b
- icd9d
- icd9e
- icd9f
- Check Box5 Off
- Check Box7 Off
- icd9b2
- icd9c2
- icd9d2
- C_2
- icd9e2
- icd9f2
- icd9a2
- icd9b3
- icd9c3
- C_3
- icd9a3
- icd9d3
- 1005d
- 1005m
- 1005y
- 1018-2 Off
- 1018-1 Off
- 1018-4 Off
- 1018-5 Off
- 1018-6 Off
- 1018-7 Off
- 1018-NA Off
- 1018-UK Off
- 1018-3 Off
- 1012-na Off
- 1012-uk Off
- Radio Button11 Off
- v1020b
- C_5
- e_5
- f_5
- C_6
- e_6
- f_6
- c_4
- e_4
- f_4
- v1020c
- v1020d
- v1020e
- v1020f
- v1020a
- e1020b
- e1020c
- e1020d
- e1020e
- e1020f
- e1020a
- ev1020b
- ev1020c
- ev1020d
- ev1020e
- ev1020f
- ev1020a
- sp12-1
- sp12-2
- Radio Button12 Off
- Radio Button13 Off
- rad0 Off
- rae0 Off
- rdf0 Off
- phhp Off
- phrp1 Off
- phot1 Off
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- ign Off
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- icdb Off
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- odit Off
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- ttdp Off
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- rt Off
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- lhk Off
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- errand Off
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- pric Off
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- ebp Off
- eem Off
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- thm Off
- tt Off
- ism Off
- ephs Off
- irle Off
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- atp Off
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- te Off
- pas Off
- sfe Off
- pom Off
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- idy Off
- vdt Off
- ar Off
- noc Off
- ldt Off
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- sps Off
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- hwi Off
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- usb Off
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- saic Off
- dptw Off
- rsm Off
- kss Off
- uhc Off
- hpa Off
- ipi Off
- grp Off
- ftcm Off
- wac Off
- ria Off
- paf Off
- pafi Off
- pwe Off
- ptc Off
- ges Off
- otp Off
- pwdf Off
- pdaf Off
- pdi Off
- pdis Off
- phas Off
- pep Off
- 12100 Off
- allepen Off
- Patient is not diabetic or is bilateral amputee
- mswref Off
- genitonoprob Off
- Urostomy describe skin around stoma Off
- nutrinoprob Off
- O2prod Off
- woraft Off
- woreve Off
- wormor Off
- worsleep Off
- prodsputcol
- fname Off
- Rehabdc1 Off
- mswgwk1
- stgwk2
- stgwk1
- stgwk3
- rhpoor Off
- Clear Form
- E-mail Form
SAFETY MEASURES LIVING ARRANGEMENTS SUPPORTIVE ASSISTANCE
Oxygen use NYSigns postedYFollow smoking flammables safety precautions N
Oxygen back-up Knows Instructed how to useAvailable
Oxygen Precautions explained
PlanComments
Safety hazards in the home (check all that apply)NYFire alarmsmoke detector Fire extinguish
Inadequate heating cooling electricity lightingHurricane Disaster Emergency supplieskits
NY
InstructionsInformation Provided Sign Up package (Check all that apply)
Y N
Patient Rights and responsibilities
NYFirst aid boxEmergency Equipment or Supplies
State hotlineABUSE number
NYUnsafe gaselectrical appliances or electrical outlets
Advance directives information
NYInadequate running water plumbing problemsDo not resuscitate (DNR) (if applicable)NUnsafe storage of supplies equipment HME
No telephone available andor unable to use the phonePest problems InsectsrodentsMedications stored safely clearly-easy use check interactions
Service AgreementContractNYOASISHIPAA Privacy Notice ConfidentialityNY
Emergency Plan classification instructionsNYAgency phone numbers addressEmergency planning Exit Plan in place more than one exitClient Information Handbook
Y N
Standard precautions handwashing Infection Control
NYEnough Ventilation
Home safety guidelines
Safe BedsChairs clear pathways
Admission criteria Information for Home visit Services FrequencyY NAble to follow directions in case of Emergency
Diabetes Control other disease management informationNYSlippery Floors Ashtrays (if a smoker)
Fall Prevention Program
NYPlan for power failure emergency lights flashlights etc
THERAPY AND PLAN OF CARE(M2200) Therapy Need in the home health plan of care for the Medicarepayment episode for which this assessment will define a case mixgroup what is the indicated need for therapy visits (total of reasonableand necessary physical occupational and speech-language pathologyvisits combined) (Enter zero [000] if no therapy visits indicated)
) Number of therapy visits indicated (total of physicaloccupational and speech-language pathology combined)
(
NA - Not applicable No case mix group defined by this assessment(M2250) Plan of Care Synopsis (Check only one box in each row) Does the physician-ordered plan of care include the following
PlanIntervention YesNo Not Applicable
a Patient-specific parameters for notifying physician ofchanges in vital signs or other clinical findings 0 1 na
Physician has chosen not to establish patient-specific parameters for this patient Agency will usestandardized clinical guidelines accessible for allcare providers to reference
b Diabetic foot care including monitoring for the presence ofskin lesions on the lower extremities and patientcaregivereducation on proper foot care
0 1 naPatient is not diabetic or is bilateral amputee
c Falls prevention interventions 0 1 na Patient is not assessed to be at risk for falls
d Depression intervention(s) such as medication referral forother treatment or a monitoring plan for current treatment 0 1 na Patient has no diagnosis or symptoms of
depression
e Intervention(s) to monitor and mitigate pain 0 1 na No pain identified
f Intervention(s) to prevent pressure ulcers 0 1 na Patient is not assessed to be at risk for pressureulcers
g Pressure ulcer treatment based on principles of moistwound healing OR order for treatment based on moistwound healing has been requested from physician
0 1 naPatient has no pressure ulcers with need for moistwound healing
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Y
NY
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Patient Name Med Record
HOME ENVIRONMENT SAFETY
NYRelevant medical appliances if applicable ( wheelchair O2 Monitors etc)NYHurricane Shutter Disaster Plan
Medication sheet reconciliatedchecked
Alzheimers Sensory impairments info
Care Plans
Pain Management info Grievance Procedures
Local Resources Guide Mission ownership information
Physical Therapy Total visitsOccupational Therapy Total visits
Speech Therapy Total visitsOther Therapy Total visits
(SOC)
Safety Measures CMS485 (POC)
Cast PrecautionsChange position slowlyCoumadinHeparin PrecautionsDo not lift bend stoopGood handwashing techniqueOxygen PrecautionFire preventionPractice Universal Precautions
15
Safe Ambulation
Respiratory PrecautionsDiabetic PrecautionsWoundDecubitus precautionsAdequate lightingPrevent Cardiac OverloadPrevent Falls and Injuries GI Precautions
Prev Infection ComplicationsSeizure PrecautionsSuicide precautionsSupport due functional limitationTeach coping skillsSafe storagedisposal syringes Cardiac Precautions
GU Precautions
Safe TransfersSAN PrecautionsCatheter CareProvide Emotional SupportEmergency Plan
Maintain Safeclear EnvironmentMaintain Good Skin care
Clear pathways
Other
SG
Correct handwashing technique SG
Check bathroom floorstairs for safety hazardsPsycho-social behavior precautions
SG
SGSG
SG
SG
SG
Other
SG
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PATIENT CARE COORDINATION
CARE PLAN Reviewed with patient involvementOrder obtainedMedication Form completedreviewedupdated No changeMEDICATION RECORD
Ineffective drug therapySignificant drug interactions
Significant side effectsNon-compliance with drug orders Duplicate drug therapy
Other (specify)M S WSNPhysician AidePT OT STCARE COORDINATION
Explain
Yes No
DME SUPPLIES
IV start kit Underpads size BathbenchChemstrips2x2sIV pole
External catheters
Syringes Cane Quad CaneIV tubing
Urinary bagpouch
COTTON TIP APP4x4s
CommodeAlcohol swabs
Ostomy pouch (brand size)
Special mattress overlayABDs
Angiocatheter size
Cotton tipped applicatorsPeroxide Ostomy wafer (brand size)
Pressure relieving device
Wound cleanserExtension tubingsWound gel
Injection caps
Stoma adhesive tape
Eggcrate
Drain sponges Central line dressing
Skin protectant
Hospital bed
GlovesNon-sterile
Side Rails
Infusion pump Hoyer lift
Sterile Batteries size Enteral feeding pump
Hydrocolloids
Enema suppliesSyringes size
Nebulizer
Kerlix size
Feeding tubeNu-gauze
MEFIX 2X11 YD (EA)
Oxygen concentrator
sizetype Suction machine
SalineNSS
FOLEYCATH SUPPLIES
Suture removal kit Ventilator
Tape
Fr catheter kit
Staple removal kit Walker
(tray bag foley)Transparent dressings
Steri strips
Straight catheter
Wheelchair
Ointment
TRIPLE ANTIBIOTIC 30GR
Irrigation tray
Tens unitSalineNSS
OtherAcetic acid
Other
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Patient Name Med Record
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PATIENTCAREGIVER INSTRUCTIONS-TEACHINGCheck all that appliesPatientcaregiver(CG) independent with
Trach care
N oYesWoundDecubitus care
Yes No
Yes N o
Ostomy care Yes
N oYesDiabetic managementcare
N o
N oYesNoYesInsulin administration N oYes
Oxygen useprecautions
Yes N oGlucometer usecalibration N oYes
Use of home medical equipmentdevices
N oYesNutritional managementDiet
NoCaregiver present during the visit Yes
PatientCG educationteaching this visit for
N oYesPatientCG able to understand instructionsteaching
Does the patientCG have a plan when disease symptoms exacerbate (eg when to call the nurseAgency vs emergency 911) N oYes
Comment(s)
SKILLED CARE PROVIDED THIS VISIT
Medication management Administration Oral Injection IV-Infused Inhaled
Foley care Yes N o
Pain ManagementHome prescribed exercisesActivities of Daily LivingPersonal Care
MEDICATION
DISEASE PROCESS COMPLICATIONSSS OFILEAL CONDUITOSTOMY SKINFOOT CAREDIET FLUIDS INFECTION CONTROL
OTHER INSTRUCTIONS GIVEN
N oYesElimination Incontinence management
NEEDS FURTHER TEACHINGExplain
NA NANANANANA
NANANANANANANA
Yes N oPhysician follow up visitsappointments NA
Expected Outcome
DISCHARGE PLANNING DISCUSSEDEXPLAINED Patient unable to perform own Wound Care dueto
Patient unable to InsulineInjection self administration dueto
No SO or CG ablewilling for wound careInsulin-Injection administration at this time
Telfa
Colostomy Supplies
Thermometer
Texas Cath
Red Box (Biohazard)
Betadine Solution
Abd Pads
Duoderm
Sharp Container
Ace band size
Leg Straps Cath
ALCOHOL PREP PADS
DUODERM CFGHY-TAPE 2INSERTION TRAY 5CC
INSULIN SYRINGE ____ CCSYRINGES
Glucometer
MICROPORE TAPE 2
SOFTWICK 4X4
VASELINE GAUZE 3X9
KLING 4
(SOC)
Medication Management Check all that appliesidentified Potential adverse effectsdrug reactionsSG
Skil led Observation AssessmentINJECTION ROUTE_______ SITE _____ MED GIVEN ______________________ DOSE __________ REACTION _____________________________
Foley ChangeCare Patient Educationteaching Wound Care Dressing Change Prep Admin Insulin
StandardUniversal Precautions Followed Aseptic Tech Used Quality Control of Glucometer Performed Sharps Discarded Inside Sharps Container
ProcedureTx welltolerated by Pt
Diabetic Observation Care
Correct handwashing technique followed SG ManagementEvaluation Patients Care Plan No caregiverfamily availablewilling to help patient with care procedures
SG
Pshycological carebehaviour problems prevention NA
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Orders by discipline (optional) To complete CMS485 (POC)
SN - ORDERS - FREQUENCYDURATION
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Patient Name Med Record
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OTHER
General
Psychiatric
F o l e y Care
REPORT ANY ELEVATIONS IN TEMPERATURE TO THE MD
Wound CareDecubitus
IMPROVE THE PTS ABILITY TO PREVENT OR COPE WITH BREATHING DIFFICULTIES
Asthma Respiratory
INST FOR SS EASY FATIGABILITY DYSPNEA PALPITATIONS ANGINA TACHYCARDIAPALLOR DIZZINESS JAUNDICE AND FEVER INST FOR G I DISTURBANCES ASSESS FOR CENTRALNERVOUS SYSTEM SYMPTOMATOLOGY OBTAIN APPROPRIATE LAB TESTS AND REPORT FINDINGS TO MD ADMINISTER PRESCRIBED INJECTABLE _________________ USING ______ TECHNIQUE
Anemia
Included as reference only your Professional Staff must reviewupdatepersonalizedapprove the orders
INSTRUCT IN PREPARATION amp ADMINISTRATION OF INSULIN INSTRUCT ONSET PEAK ampDURATION OF ACTION OF INSULIN INSTRUCT PROPER DISPOSAL OF SYRINGESNEEDLES NURSE TO MONITOR BLOOD SUGAR WITH GLUCOMETER OR ___________ON __________FREQUENCY ampNOTIFY MD OF ALTERED RESULTS TEACH GLUCOMETER OR __________ PROCEDURE amp INTERPRETING RESULTS
InsulinGlucometer
INST DISEASE PROCESS amp COMMON COMPLICATIONS INST PRESCRIBED DIET amp SHOPPING ADVICE INST SSHYPOHYPERGLYCEMIA amp EMERGENCY PROCEDURES INST GOOD SKIN CARE amp GOOD FOOT CARE DAILY CARE OFTEETH INST DIABETIC CHART INST SampA TESTING amp READING RESULTS INSTRUCT TO CARRY ID THAT INCLUDESINFORMATION REGARDING DIABETIC STATUS NAMES amp DOSAGE OF MEDS amp ACTION TO TAKE IF INSULIN REACTION OCCURS INST IMPORTANCE OF GOOD PERSONAL HEALTH HABITS INCLUDING EXERCISE ADEQUATEREST SLEEP REGULAR MED CHECK-UPS (INCLUDING PODIATRIC OPTHAMOLOGIST amp DENTIST)
DiabetesMellitus
INST PACED ACTIVITY PROGRAM
OBSERVE FOR SS OF DECOMPENSATION SUCH AS INCREASING TACHYCARDIA WSUDDEN ONSET SOB ON MINEXERTION ORTHOPNEA EXTREME ANXIETY PROGRESSIVE CYANOSIS GENERALIZED PALLOR AND DIAPHORESISCHF
INSTRUCT PROPER ADMINISTRATION OF OXYGEN THERAPY INSTRUCT OXYGEN PRECAUTIONSINSTRUCT MAINTENANCE OXYGEN EQUIPMENTOxygen
ASSESS FOR CHEST PAIN TYPE LOCATION INTENSITY DURATION amp FREQUENCY IS PAINMANAGEMENT NOTIFY MD IF PAIN PERSISTS IS GRADUAL PROGRESS ACTIVITY INCREASEINST DISCONTINUE ACTIVITY IF CHEST PAIN DYSPNEA FATIGUE OR PALPITATIONS OCCUR
Angina
PSYCHOLOGICAL ASSESSMENT ASSESS NEUROLOGICAL STATUS IMPLEMENT AND MONITOR BOWEL REGIMEN ampTEACH PROGRAM TO FAMILY SN TO MONITOR TRANQUILIZER EFFECTS GIVEN FOR SEVERE AGITATIONANXIETYEVALUATE FOR WEIGHT LOSS WEIGH PATIENT Q VISIT AND RECORDS WEIGHTS MONITOR LEVEL OFCONSCIOUSNESS ASSESS COORDINATION AND BALANCE PROVIDE EMOTIONAL SUPPORT TO PATIENT ANDFAMILY OBSERVATION AND EVALUATION OF BLADDER ELIMINATION HABITS MANAGEMENT IF INCONTINENCEASSIST FAMILY IN SETTING UP ROUTINE PATIENT-CENTERED AND STRESS THE IMPORTANCE OF ADHERING
Alzheimers
AIDE - ORDERS - FREQUENCYDURATIONTUBSHOWER BATH PERSONAL CARE HAIR COMB SHAMPOO PRN MOUTHDENTURE CARE SKIN CHECK ORAL HYGIENE TPRASSIST TO DRESS ASSIST WITH AMBULATION PREPARE SERVE MEALS GROCERY SHOP WASH CLOTHES LIGHT HOUSEKEEPING ASSIST WITH PERSONAL CARE AND ADLSERRANDS NOTIFY LAST BM IF NONE FOR 3 DAYS FEETNAILS CARE PERI CARE REPORT SIGNIFICANT FINDING TO SN STRAIGHTEN ROOM amp CHANGE LINEN
PT - ORDERS - FREQUENCYDURATIONEVALUATE BALANCE AND COORDINATION EVALUATE ENDURANCE MOBILITY NEUROMUSCULAR RE-EDUCATIONPERFORM PRESCRIBED THERAPEUTIC EXERCISES NOTIFY SIGNIFICANT FINDING TO MDAGENCY BED MOBILITY TRAININGGAIT TRAINING WITH ASSISTIVE DEVICE TEACH HOME MAINTENANCE PROGRAM AND STRENGTHENING EXERCISEEXERCISE BOTH PASSIVE AND ACTIVE EXERCISE REGIMEN TRANSFER TRAINING INSTRUCT IN SAFETY MEASURES FALL PRECAUTIONS
OT - ORDERS - FREQUENCYDURATIONEVALUATE PATIENT AND HOME FOR SAFETY ADL TRAINING PROGRAM MUSCLE RE-EDUCATION BODY IMAGE TRAININGINCREASE RIGHT AND LEFT UPPER EXTREMITIES STRENGTH THERAPEUTIC EXERCISE TO (R) AND (L) HANDINCREASE STRENGTH AND COORDINATION PROPRIOCEPTION AND SENSATION
ST FOR EVALUATION TO PROVIDE ORAL MOTOR EXERCISES INVOLVING LINGUAL AND LABIAL EXERCISES SPEECH ARTICULATION DISORDER TREATMENTIMPROVE SPEECH FACIAL SYMMETRY AND MUSCULATION IMPROVE DYSPHAGIA VOICE DISORDER TREATMENT AURAL REHABILITATION NON-ORAL COMMUNICATION LANGUAGE DISORDER TREATMENT
ST - ORDERS - FREQUENCYDURATION
MSW - ORDERS - FREQUENCYDURATIONMSW FOR ASSESSMENT OF SOCIAL AND EMOTIONAL FACTORS COMMUNITY RESOURCE PLANNINGCOUNSELING REGARDING MANAGEMENTADJUSTMENT TO ILLNESS LONG RANGE PLANNING AND DECISION MAKING
PROVIDE SUPPORTIVE AND RELAXATION THERAPY PROVIDE FAMILY THERAPY ASSESS INTERPERSONALBEHAVIOR ASSIST PATIENT TO DEFINE PROBLEMS amp SOCIAL RELATIONSHIPS GIVE POSITIVE REINFORCEMENTASSIST PATIENT TO VERBALIZE FEELINGS
Anxie ty
INST DISEASE PROCESS AND COMMON COMPLICATIONS INST LOW SODIUM DIET - STRESSING IMPORTANCE OFADHERENCE MONITOR PATIENTS BLOOD PRESSURE CLOSELY AND NOTIFY MD OF ANY SIGNIFICANT CHANGESINSTRUCT PT TO AVOID OVER-THE-COUNTER COLD AND SINUS MEDS AS THEY CONTAIN VASOCONSTRICTORINST OF HYPERTENSIVE CRISIS MONITOR FOR SS OF ORTHOSTATIC HYPOTENSION
Hypertension
ASSESS PSYCHOLOGICAL STATUS PROVIDE SUPPORTIVE THERAPY PROVIDE REMOTIVATION ASSESSINTERPERSONAL BEHAVIOR ASSIST PATIENT TO DEFINE PROBLEMS amp SOCIAL RELATIONSHIPS GIVE POSITIVEREINFORCEMENT ENCOURAGE PATIENT TO PERFORM PERSONAL HYGIENE amp GROOMING ACTIVITIESASSIST PATIENT TO EXPRESS REALISTIC IDEAS amp PLANS ASSIST PATIENT TO VERBALIZE FEELINGS
Depression
INSTRUCT PATIENT IN CONSEQUENT PHYSICAL L IMITATIONS PLANNING AN ADEQUATE LEVEL OF DAILYACTIVITIES TEACH PT RE ARTHRITIS SS OF EXACERBATION TEACH THE IMPORTANCE OF GOOD POSTUREPREVENT TRAUMA TO JOINTS INST PT IN THE USE OF ASSISTIVE DEVICE AS PRESCRIBED
Osteoarthritis
SKILLED OBSERVATIONEVALUATION ASSESS VITAL SINGS amp SS COMPLICATIONSINSTRUCTEVALUATE UNDERSTANDING OF DISEASE PROCESS DETECTING COMPLICATIONSDIETNUTRITIONAL STATUS SAFETY PRECAUTIONEMERGENCY MEASURES MED-REGIMEN
PSYCH ASSESSMENT ASSESS FOR SS OF EPSDETECT AND ALLEVIATE SOMATIZED COMPLAINTSLIMIT SETTING MOTIVATION TECHNIQUES IMAGERY TECHNIQUES
RELAXATION TECHNIQUESGOAL ORIENTED TASKS
FOLEY INSERTION _______FR FOLEY WITH___________cc BALLONCHANGE Q MONTH amp PRN x3 FOR CLOGGED LEAKING OR ACCIDENTAL REMOVALINST DRESSING CHANGES ________________________ MONITOR FOR SS COMPLICATIONS amp NOTIFY MD
INST SS INFECTION
MONITOR STATUS OF WOUND OR DECUBITUS (place) ______________INST INFECTION CONTROL MEASURES
INST GOOD NUTRITION TO FACILITATE HEALINGMEASURE AND RECORD WOUND or DECUBITUS SIZE AT SOC AND AT LEAST WEEKLY THEREAFTEROPEN WOUND CAREDRESSING CLEANSE WOUND WITH ___________ TO RINSE WITH __________ AND APPLY______________ AND PRN
OBSERVE AND RECORD TYPE AND AMOUNT OF DRAINAGE COLOR INFECTION SWELLING REDNESS PAINDE CUB ITUS CAR EDR ESS ING CLEAN SE W OUN D WITH ___________ TO R IN SE WITH __________ AN D APP LY ______________ AN D PR N
TEACH THE PATIENT HOW TO USE A METERED-DOSE INHALER MAINTAIN EFFECTIVE AIRWAY CLEARANCE
EMPHASIZE THE IMPORTANCE OF ADEQUATE DAILY FLUID INTAKE
PROMOTE AN EFFICIENT BREATHING PATTER
INST INFECTION CONTROL amp PULMONARY HYGIENE INST COMPLICATIONS IN CARDIOPULMONARY STATUSINST PREVENTION OF COMPLICATIONS IE AVOID OVER-EXERTION CHILLING CROWDS ETC
INST D ISEASE PROCESS amp MAINTENANCE
INSTRUCT COUGHING DEEP BREATHING EXERCISES INST PATIENT TO MAINTAIN ADEQUATE REST PATTERN
MANAGEMENT AND EVALUATION OF A PATIENT CARE PLAN TEACHING AND TRAINING DISEASE PROCESS SKIN CARE WOUND CAREDRESSING CHANGE DECUBITUS CARE MEDICATION REGIMEN DIETNUTRITIONHYDRATION COMPLICATIONS OF ENT FEEDING AS INDICATED
PAIN CONTROL MEASURES SYMPTOM CONTROL MEASURES SINGSSYMPTOMS OF INFECTION SAFETYPREVENTION OF INJURY EMERGENCY PLANS OXYGEN ADMINISTRATION
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GOALSREHABILITATION POTENTIAL CMS485 (POC)Included as reference only your Professional Staff must reviewupdatepersonalizeapprove the goals
DISCHARGE PLANNING DISCUSSED WITH PATIENT Yes No REHAB POTENTIAL ExcellentPoor Fair Good
SIGNATUREDATES
X DateStaff Completing the OASIS (signaturetitle)
OASIS INFORMATION
Data Entry Date amp Locked Date SubmittedQA Date Reviewed
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SN - GOALSMRMS _________________ WILL EXHIBIT VITAL SIGNS WITHIN ACCEPTABLE RANGE AND STABILIZED DISEASE PROCESSVERBALIZES KNOWLEDGE OF DISEASE MANAGEMENT MEDICATIONS SIDE EFFECTS PRECAUTIONS DIET FLUIDS TREATMENT PROGRAM SS NECESSITATING MEDICAL ATTENTION EMERGENCY CARE
STABILIZATION OF PSYCHOLOGICAL STATUS WITHIN DISEASE LIMITS TO REDUCE THE PATIENTS ANXIETY LEVELDEPRESIONANXIETY CONTROLED TROUGH MED REGIMEN INTERVENTIONS
ANEMIA CONTROLLED THROUGH MED REGIMEN IMPROVED HEMATOLOGIC STATUS
General
Psychiatric
A n e m i aHEALED WOUND WITHOUT INFECTION OR COMPLICATIONS DEMONSTRATE PROPER WOUND CARE
Wound Care
PTSO SHOULD UNDERSTAND THE NATURE SYMPTOMS STAGE AND PROGRESSION OF ALZHEIMERS DISEASEKNOW HOW TO RECOGNIZE PTS OWN STRESS AND WAYS TO PREVENT OR REDUCE IT PROMOTE SOCIAL INTERACTION AS TOLERATED BY THE PATIENT
Decubitus
DEMONSTRATE STRATEGIES TO BE USED DURING A COUGHING EPISODE HELP THE PATIENT IDENTIFY FACTORSTHAT MAY CAUSE ASTHMA ATTACKS OR CONTRIBUTE TO THEMAsthma
SAFELY ADMINISTERS INJECTION COMPREHEND RATIONALE FOR AND IS ABLE TO ROTATE INJECTION SITESCOMPREHEND SAFETY FACTORS IN SYRINGENEEDLE DISPOSALPATIENTCG ABLE TO MONITOR BLOOD SUGAR CORRECTLY WITHOUT ASSISTANCEABLE TO NOTIFY MD OF ALTEREDOUT OF RANGE RESULTS
InsulinGlucometer
DISCHARGE PT WHEN BLOOD SUGARS ARE WITHIN THE NORMAL FOR PATIENT RANGEKNOW THE ACCEPTABLE RANGE FOR BLOOD SUGAR LEVEL COMPLY WITH DIET RESTRICTIONS Diabetes
MellitusRETURN TO SELF-MANAGEMENT OF HEALED FRACTURED
FractureKNOW ABOUT SIGNS SYMPTOMS AND PRECIPITATING CAUSES OF CHF KNOW HOW TO TAKE THE PULSE AND KNOWTO CONSULT THE DOCTOR BEFORE CONTINUING MEDICATION IF THE PULSE RHYTHM CHANGES KNOW TOA V O I D S M O K I N G A N D S M O K Y E N V I R O N M E N T S A N D P E R S O N S W I T H I N F E C T I O N S E S P E C I A L L Y R E S P I R A T O R Y I N F E C T I O N S
CHF
UNDERSTAND THAT HYPERTENSION IS A CHRONIC DISEASE REQUIRING LIFE LONG TREATMENT EXHIBIT BLOODPRESSURE READINGS CONSISTENTLY WITHIN NORMAL OR SPECIFIED RANGE DEMONSTRATE ADHERENCE TO ALOW-SALT LOW-FAT DIET
Hypertension
HELP THE PATIENT ACHIEVE PAIN RELIEVE AND REDUCE ANGINA EPISODES UNDERSTAND THE CAUSE OFANGINA PECTORIS AND POSSIBLE PRECIPITATING FACTORS FOR AN ATTACK IDENTIFY PERSONAL STRESSORSTHAT MAY CONTRIBUTE TO THE PROBLEM AND BEGIN ELIMINATING OR MINIMIZING THEM KNOW WAYS TOREDUCE THE FREQUENCY OF ANGINA EPISODES
Angina
HEALED DECUBITUS WITHOUT INFECTION OR COMPLICATIONS DEMONSTRATE PROPER DECUBITUS CARE
Alzheimers
UNDERSTAND SS OF BRONCHITIS OR OTHER RESPIRATORY INFECTION AND DISEASE EXACERBATIONUNDERSTAND THE DANGERS OF SMOKING AIR AND CHEMICAL POLLUTANTS AND RESPIRATORY INFECTIONUNDERSTAND AND PRACTICE COUGHING AND DEEP-BREATHING EXERCISES
Respiratory
DAILY COMPLIANCE WCATHETER CARE DECREASE RISK OF URINARY INFECTIONCatheter
INCREASED PAIN RELIEF INCREASED STRENGTH AND ENDURANCE COMPREHEND AND DEMONSTRATE HOME EXERCISEOsteoarthritis
AIDE - GOALS
GAIT PATTERN ENDURANCE STRENGTH AND BALANCE WILL IMPROVE AND PATIENT WILL DEMONSTRATECORRECT BODY MECHANICS WIN 4-6 WKS PTCG WILL COMPREHEND AND DEMONSTRATE HOME EXERCISEPROGRAM WITHIN 4-6 WKS
FAIR-TO BE ABLE TO CARRY OUT MINIMAL ADLS WITH AVAILABLE HOME SUPPORTWILL NOT BE ABLE TO CARRY OUT ADLS WITHOUT MAXIMUM SUPPORT
RETURN TO INDEPENDENT AMBULATION BE SAFE IN SELF CAREPATIENT WILL BE ABLE TO FUNCTION WITH ASSISTANCE OF CAREGIVERWITHIN HESHE CURRENT LIMITATIONS AT HOME
PATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HISHER CURRENT LIMITATIONS AT HOME
PT - GOALS
GOOD RETURN TO PREVIOUS LEVEL OF ADLS INDEPENDENTLY
GAIT PATTERN ENDURANCE STRENGTH AND BALANCE WILL IMPROVE AND PT WILL DEMONSTRATECORRECT BODY MECHANICS WITHIN _____ WEEKS
PATIENT WILL EXPERIENCE A DECREASE IN PAIN
PTCG WILL COMPREHEND AND DEMONSTRATE HOME EXERCISEPROGRAM WITHIN _____ WEEKS
OT PATIENT WILL EXHIBIT IMPROVEMENT IN COPING IN ADLSIADLS MUSCLE USEMOTORCOORDINATIONNEURO RESPONSEUSE OF ORTHOTIC SPLINTING ANDOR EQUIPMENT
OT - GOALS
PATIENT WILL DEMONSTRATE FUNCTIONAL COMMUNICATIONS EXHIBIT MAXIMUM VERBAL AND SENTENCEFORMULATION AND COMPREHENSION WITHIN DISEASE LIMITS WITHIN _____ WEEKS
ST - GOALS
PATIENT WILL DEMONSTRATE APPROPRIATE USE OF FUNCTIONAL VERBALNON-VERBALCOMMUNICATIONS SYSTEMS WITHIN _____ WEEKS
PATIENT WILL DEMONSTRATE IMPROVED READINGWRITING USE OF GESTURESNUMBERS WITHIN _____ WEEKS
PATIENT WILL DEMONSTRATE IMPROVED SWALLOWINGCHEWINGORALMOTOR CONTROL WITHIN _____ WEEKS
PATIENT WILL HAVE ADEQUATE SUPPORT TO REMAIN IN HOME WITH ASSISTANCE OF COMMUNITYRESOURCES FOR FINANCIAL TRANSPORTATION AND PERSONAL CARE ASSISTANCE WITHIN _____ WEEKS
MSW - GOALSPSYCHOSOCIAL EVALUATION WILL BE PERFORMED PTCG WILL BE COUNSELED REGARDING MANAGEMENTamp ADJUSTMENT TO ILLNESS LONG TERM PLANNING AND DECISION MAKING APPROPRIATE COMMUNITYRESOURCE REFERRALS WILL BE MADE
WILL DISCHARGE THE PATIENT WITHIN 60 DAYS WHEN PATIENT ANDORCAREGIVER ISARE ABLE TO DEMONSTRATE KNOWLEDGE OF DISEASE MANAGEMENT SS COMPLICATIONSPATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HISHER CURRENT LIMITATION AT HOME
ABLE TO REMAIN IN HOMERESIDENCEALF WITH ASSISTANCE OF PRIMARY CAEGIVERSUPPORT AT HOMEABLE TO UNDERSTAND MEDICATION REGIMEN AND CARE RELATED TO HISHER DISEASEWILL BE DISCHARGE WHEN MAXIMUM FUNCTIONAL POTENTIAL REACHED
Patient Name Med Record
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XPatient Signature if required optional if itinerary is used
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- PT ID PERFORMED VIA NAME DOB FACE RECOGNITION AND ADDRESS BEFORE SERVICE PROVIDED Off
- TIME IN
- TIME OUT
- Agency Name SALUD HOME CARE INC
- Phone 305-555-5555
- Employees NameTitle Completing the OASIS
- who has signed the plan of care
- Physician name
- Address 1
- Address 2
- Phone Number
- Address 1_2
- Address 2_2
- Patient Phone
- Reason
- Name
- Other Physician if any
- Phone_2
- Address 1_3
- Address 2_3
- Phone Number_2
- REFERRAL SOURCE if not from Primary Physician
- undefined_6
- Phone_3
- Fax
- Evacuation Form needed Emergency Reg 1
- Evacuation Form needed Emergency Reg 2
- EMERGENCY CONTACT
- Address
- Comments 1
- Comments 2
- Phone_4
- Relationship
- OTHER
- Comment 1
- Comment 2
- 11 Other specify
- a
- b
- 7 Other specify
- c
- d
- e
- f
- a_2
- b_2
- d_2
- e_2
- f_2
- a_3
- b_3
- d_3
- Comment if needed 1
- Comment if needed 2
- a_4
- a_5
- a_6
- Date 23
- undefined_7
- undefined_8
- b_4
- b_5
- b_6
- Date_2
- undefined_9
- undefined_10
- Date_3
- undefined_11
- undefined_12
- d_4
- d_5
- d_6
- Date_4
- undefined_13
- undefined_14
- Date_5
- undefined_15
- undefined_16
- Date_6
- undefined_17
- undefined_18
- 12 1
- 12 2
- Date_7
- undefined_19
- undefined_20
- Date_8
- undefined_21
- undefined_22
- MAIN REASON FOR HOME HEALTH CARE 1
- MAIN REASON FOR HOME HEALTH CARE 2
- Fractures site
- Surgeries site
- Cancer site
- Open Wound site
- Decubitus site
- Other specify
- Other
- Pending or Needed
- Yes Number of times
- Reason s Dates
- MobilityAmbulatory devices used
- Other specify_2
- undefined_23
- Comments if needed 1
- Comments if needed 2
- Comments if needed 3
- Comments if needed 4
- undefined_24
- Name_2
- Phone number if different from patient
- Relationshiphealth statusability to help 2
- Any paid help explain
- Specify 1
- Specify 2
- Specify 3
- Any ears surgeryprocedure
- Date_9
- Otherspecify 1
- Otherspecify 2
- Other agencies involved in care 1
- Other agencies involved in care 2
- 1
- 2
- Other_2
- Infections
- Cataract surgery Site
- Date_10
- Other eyes surgery Site
- Date_11
- explain 1
- explain 2
- Any nose surgery
- Date_12
- Other specify_3
- 1_2
- 2_2
- MassesTumors site
- Lesions explain
- Any surgeryprocedure
- Other specify 1
- Other specify 2
- Other specify 3
- Date_13
- Other specify_4
- No Problem
- Medication
- Other_3
- Pain control treatmentmeds Side effect mark
- Other_4
- Is there a regular pattern to the pain explain
- Other_5
- Comment
- What was the outcome
- Type II OnsetExacerbation date
- DietOral control specify
- INSULIN dosage frequency scale explain
- 1_3
- 2_3
- Since
- Other_6
- A1c
- BS
- mgdL DateTime
- Blood sugar ranges
- site 1Location site
- site 2Location site
- site 3Location site
- Frequency
- Other_7
- site 1New Onset Exacerbation
- site 2New Onset Exacerbation
- site 3New Onset Exacerbation
- Able to use Glucometer
- site 1Present level 010
- site 2Present level 010
- site 3Present level 010
- Diabetes Management Problems explain 1
- Diabetes Management Problems explain 2
- Other Endocrine problems
- site 1Occasional y Cont Intermittent Frequency Frequently
- site 2Occasional y Cont Intermittent Frequency Frequently
- site 3Occasional y Cont Intermittent Frequency Frequently
- site 1Pain type ach ng burn ng rad ating neura gia etc
- site 2Pain type ach ng burn ng rad ating neura gia etc
- site 3Pain type ach ng burn ng rad ating neura gia etc
- Anemia specify type if known
- site 1Feeling of pain internal external acute chronic
- site 2Feeling of pain internal external acute chronic
- site 3Feeling of pain internal external acute chronic
- site 1Pain is worse morning
- site 2Pain is worse morning
- site 3Pain is worse morning
- Immunodeficiency problems explain
- Other 1
- Other 2
- Other_8
- explain 1_2
- explain 2_2
- explain 3
- explain 4
- Other specify 1_2
- Other specify 2_2
- undefined_25
- undefined_26
- undefined_27
- undefined_28
- undefined_29
- undefined_30
- undefined_31
- undefined_32
- undefined_33
- undefined_34
- undefined_35
- undefined_36
- M1310 Pressure Ulcer Length Longest length headtotoe
- undefined_37
- cm
- greatest width perpendicular to the length
- M1314 Pressure Ulcer Depth Depth of the same pressure ulcer from
- cm_2
- visible surface to the deepest area
- undefined_38
- cm_3
- 1_4
- 2_4
- 3_2
- Other_9
- 4_2
- Caregiver name
- Other_10
- cant integument findings
- Observation
- Observation_2
- Caregiver name_2
- Other_11
- Wound cleaned with specify
- Wound irrigated with specify
- 1 Size
- cm width
- Wound packed with specify
- Location
- Other_12
- Wound dressingcover applied specify
- 2 Size
- cm width_2
- Comments 1_2
- Comments 2_2
- Location_2
- Other_13
- Sizecm LengthxWidthxDepth
- Sizecm LengthxWidthxDepth_2
- Diagram 4Sizecm LengthxWidthxDepth
- Tunneling Undermining cm
- Tunneling Undermining cm_2
- Diagram 4Tunneling Undermining cm
- Stage IIIIIIIV pressure uIcers only
- Diagram 4Stage IIIIIIIV pressure uIcers only
- Odor Fool normal etc
- Diagram 4Odor Fool normal etc
- Edema pedal sacral p tting etc
- Diagram 4Edema pedal sacral p tting etc
- Appearance of the Wound Bed
- Diagram 4Appearance of the Wound Bed
- Treatment Ordered
- Diagram 4Treatment Ordered
- Other_14
- Other_15
- Other_16
- Other_17
- Yes 1
- Yes 2
- Yes 3
- Height
- Weight
- Radiating to
- GainLoss
- lb X
- Frequencyduration
- Sittinglying R
- L
- Standing R
- L_2
- Medication_2
- Temperature
- Other_18
- Apical
- Brachial
- Radial
- Carotid
- Dependent
- Pitting 1234
- Respirations
- Site
- Cramps site
- Disease Management Problems explain
- Right Upper
- Right
- Right Lower
- 1_5
- 2_6
- 3_3
- Left
- Left Upper
- Left Lower
- Pacemaker Date
- Last date checked
- SOB on minimal effortwalk
- Type
- fy
- Other Prob 1
- Other Prob 2
- O2
- Trach sizetype
- CaregiverfamilyOther
- Yes explain 1
- Yes explain 2
- Other_19
- Comments 1_3
- Comments 2_3
- Increase fluids
- Restrict fluids
- Frequency_2
- Amount
- Yes describe 1
- Yes describe 2
- Frequency_3
- Other 1_2
- Other 2_2
- Nocturia x
- Bowel Off
- undefined_52
- Diapersother
- Other_20
- No
- 2TOTAL
- Urinary Catheter Type
- Last changed on
- Foley inserted date
- with
- Inflated balloon with
- Irrigation solution Type specify
- Amount_2
- mL Frequency
- Returns
- No_2
- 1_6
- 2_7
- Describe at risk intervention and plan 1
- Describe at risk intervention and plan 2
- Describe at risk intervention and plan 3
- DischargeDrainage describe
- Lesions
- Blisters
- Masses
- Cysts
- Wart
- Other specify_5
- Surgical alteration
- Prostate problem BPH TURP Date
- undefined_53
- undefined_54
- Selftesticular exam Frequency
- Hysterectomy Date
- undefined_55
- undefined_56
- Date last PAP
- undefined_57
- undefined_58
- Results
- Breast selfexam frequency
- Mastectomy R L Date
- undefined_59
- undefined_60
- Other specify_6
- Last BM
- Diarrhea Frequency
- Bowel regimeprogram
- Incontinence Off
- Urinary Off
- Diapersother_2
- Other_21
- te describe skin around stoma
- Ileostomycolostomy s 2
- Ileostomycolostomy s 3
- Ileostomycolostomy s 4
- Ileostomycolostomy s 5
- Headache Location
- Frequency_4
- Other_22
- Migraine Frequency
- Site_2
- Weakness UE LE Location
- Other specify_7
- Site_3
- IV
- Pump typespecify
- Hand grips Equal Unequal specify
- Feedings Type amtrate
- Strong Weak specify
- Psychotropic drug use specify
- Flush Protocol amtspecify
- DoseFrequency
- Other_23
- Other specify 1_3
- Other specify 2_3
- DressingSite care specify 1
- DressingSite care specify 2
- Interventions instructionsComments 1
- Interventions instructionsComments 2
- Following Un
- versalStandard precautions
- NA
- No Problem_2
- Pain Frequency
- Abdominal girth
- Bowel sounds active absent hypo hyperactive x
- 3 Forgetful Off
- 4 Depressed Off
- 6 Lethargic Off
- 5 Disoriented Off
- 7 Agitated Off
- 2 Comatose
- 8 Other Off
- Forgetful at times Off
- Irritable Off
- Anxious Off
- Alert Off
- Describe 1
- Describe 2
- undefined_61
- Needs interpreter
- Comments 1_4
- Comments 2_4
- Higher Educational Level
- Fracture location
- Swollen painful joints specify
- Explain
- Contractures Joint
- Spiritual resource
- Location_3
- Phone No
- Atrophy
- Other_27
- Explain 1
- Explain 2
- Decreased ROM
- Paresthesia
- Weakness
- Other_28
- Inappropriate followthrough in past
- Amputation BKAKUE RL specify 1
- Amputation BKAKUE RL specify 3
- Amputation BKAKUE RL specify 4
- Treatment
- Treatment_2
- Other specify 1_4
- Other specify 2_4
- History of Falls past 3 months 12 falls M1032
- V s on Status Poor w or w o glasses M1200
- Vision Status Poor Legally blind M1200
- Gait and Balance Balance problem while standing
- Gait and Ba ance Balance problem while walking
- Gait and Balance Decreased muscular coordination
- Pred spos ng D seases 12 present
- Predisposing D seases 3 or more present
- Equipment Issues Oxygen tubing
- 1Row1
- PlanComments 1
- PlanComments 2
- Comment_2
- undefined_62
- b Ambulation
- c Transfer
- DOther specify
- 7Independent in home 1
- 7Independent in home 2
- Other 1_3
- Other 2_3
- Typebrand
- Size
- Gauge
- Length
- Insertion site
- Insertion date
- Flush solution
- Frequency_5
- Injection cap change frequency
- Dressing change frequency
- Other_29
- Siteskin condition
- External catheter length
- OtherComment
- fluid overload Other
- Circumference of arm
- Huber gaugelength
- Yes date
- Last flushed date
- Siteskin condition_2
- Infusion solution typevolumerate
- Dressing
- OtherComment 1
- OtherComment 2
- Drug Name
- Dose
- Route
- Frequency_6
- Duration of therapy
- Drug Name_2
- Dose_2
- Route_2
- Frequency_7
- Duration of therapy_2
- CommentPlan 1
- CommentPlan 2
- Pump type specify
- Other_30
- Lab draws
- Infusion care provided during visit 1
- Infusion care provided during visit 2
- Infusion care provided during visit 3
- Antibiotic therapy
- 1_7
- 2_8
- Other_31
- Removing line date if know
- BraceOrthotics specify 1
- BraceOrthotics specify 2
- BraceOrthotics specify 3
- Needs specify 1
- Needs specify 2
- Oxygen HME Co
- Prosthesis RUE RLE LUELLEOther
- HME Rep
- Grab bars BathroomOther
- Hospital bed Semielec Crank Spec
- Other_32
- NA_2
- Phone_5
- n care
- PlanComments
- N
- Other_33
- undefined_63
- Physical Therapy Total visits
- Speech Therapy Total visits
- visits
- Other Therapy Total visits
- Patient is not assessed to be at risk for falls
- No pain identified
- Patient has no pressure ulcers with need for moist wound healing
- O
- Noncompliance with drug orders
- Expected Outcome
- Patient unable to perform own Wound Care due
- Pat
- to
- Abd Pads Off
- Underpads size
- undefined_68
- Special mattress overlay
- Angiocatheter size
- Ostomy pouch brand size
- Pressure relieving device
- Ostomy wafer brand size
- undefined_69
- SYRINGES
- Batteries size
- Skin protectant
- Glucometer
- Hydrocolloids
- undefined_70
- FOLEYCATH SUPPLIES
- Syringes size
- size
- Oxygen concentrator
- Feeding tube
- Ointment
- Acetic acid
- Other 1_4
- Other 2_4
- Other 3
- Tens unit
- KLING 4
- Other 1_5
- Other 2_5
- Other 3_2
- PatientCG educationteaching this visit for
- MEDICATION Off
- DISEASE PROCESS COMPLICATIONS Off
- undefined_71
- SS OF Off
- ILEAL CONDUITOSTOMY Off
- DIET FLUIDS Off
- undefined_72
- undefined_73
- SKINFOOT CARE Off
- INFECTION CONTROL Off
- OTHER INSTRUCTIONS GIVEN
- Caregiver present during the visit
- NEEDS FURTHER TEACHING Off
- No_3
- Skilled Observation Assessment
- ent Educat
- Wound Care Dress
- Diabetic Observation Care
- Correct handwashing technique followed SG 1
- Correct handwashing technique followed SG 2
- Correct handwashing technique followed SG 3
- Correct handwashing technique followed SG 4
- 21 Included as reference only your Professional Staff must reviewupdatepersonalizedapprove the orders
- SN ORDERS FREQUENCYDURATION
- S COMPLICATIONS
- TH GLUCOMETER OR
- ON
- TEACH GLUCOMETER OR
- NSERTION
- TH
- INST DRESSING CHANGES
- MONITOR STATUS OF WOUND OR DECUBITUS place
- ADMINISTER PRESCRIBED INJECTABLE
- USING
- TH_2
- TH_3
- AND APPLY
- CLEANSE WOUND WITH
- NSE WITH
- AND APPLY_2
- OTHER_2
- DE ORDERS FREQUENCYDURATION
- PT ORDERS FREQUENCYDURATION
- OT ORDERS FREQUENCYDURATION
- ST ORDERS FREQUENCYDURATION
- MSW ORDERS FREQUENCYDURATION
- Included as reference only your Professional Staff must reviewupdatepersonalizeapprove the goals 22
- MRMS
- PROGRAM WITHIN
- CORRECT BODY MECHANICS WITHIN
- COMMUNICATIONS SYSTEMS WITHIN
- undefined_75
- undefined_76
- Date_14
- QA Date Reviewed
- undefined_77
- undefined_78
- Data Entry Date Locked
- undefined_79
- undefined_80
- Date Submitted
- undefined_81
- undefined_82
- SOCD
- SOCM
- SOCY
- SOCM1
- SOCD1
- SOCY1
- Check Box2 Off
- Check Box3 Off
- Check Box4 Off
- TOM
- TOD
- TOY
- FDM
- FDD
- FDY
- Prov 1071523
- BrID
- Check Box9 Yes
- BrIDno
- Check Box11 Off
- DLCM
- DLCD
- DLCY
- LVM
- LVD
- LVY
- DNR1 Off
- Check Box19 Off
- STFL
- PZC
- MCN
- NOMC Off
- SSN1
- SSN2
- SSN3
- SSUK Off
- MAN
- MAUK Off
- DOBM
- DOBD
- DOBY
- SEX Off
- MR
- First
- MI
- Last
- Suffix
- RACE2 Off
- RACE3 Off
- RACE4 Off
- RACE5 Off
- RACE1 Off
- RACE6 Off
- PS3 Off
- PS0 Off
- PS1 Off
- PS4 Off
- PS5 Off
- PS6 Off
- PS7 Off
- PS8 Off
- PS9 Off
- PS10 Off
- PS11 Off
- PS2 Off
- PSUK Off
- Ecode
- COMP Off
- DACM
- DACD
- DACY
- REA Off
- DM
- DD
- DY
- RDM
- RDD
- RDY
- REFDM
- REFDD
- REFDY
- EPT Off
- 14D2 Off
- 14D3 Off
- 14D4 Off
- 14D5 Off
- 14D6 Off
- 14D7 Off
- 14D8 Off
- Check Box39 Off
- icd9c
- icd9a
- icd9b
- icd9d
- icd9e
- icd9f
- Check Box5 Off
- Check Box7 Off
- icd9b2
- icd9c2
- icd9d2
- C_2
- icd9e2
- icd9f2
- icd9a2
- icd9b3
- icd9c3
- C_3
- icd9a3
- icd9d3
- 1005d
- 1005m
- 1005y
- 1018-2 Off
- 1018-1 Off
- 1018-4 Off
- 1018-5 Off
- 1018-6 Off
- 1018-7 Off
- 1018-NA Off
- 1018-UK Off
- 1018-3 Off
- 1012-na Off
- 1012-uk Off
- Radio Button11 Off
- v1020b
- C_5
- e_5
- f_5
- C_6
- e_6
- f_6
- c_4
- e_4
- f_4
- v1020c
- v1020d
- v1020e
- v1020f
- v1020a
- e1020b
- e1020c
- e1020d
- e1020e
- e1020f
- e1020a
- ev1020b
- ev1020c
- ev1020d
- ev1020e
- ev1020f
- ev1020a
- sp12-1
- sp12-2
- Radio Button12 Off
- Radio Button13 Off
- rad0 Off
- rae0 Off
- rdf0 Off
- phhp Off
- phrp1 Off
- phot1 Off
- phoa1 Off
- phfc1 Off
- phca1 Off
- phin1 Off
- phga1 Off
- phif1 Off
- phsg1 Off
- phwd1 Off
- phdc1 Off
- phgn1 Off
- rddmi Off
- imin Off
- inh1n1 Off
- fwpn Off
- fwtn Off
- fwot Off
- phdm1 Off
- PHNY Off
- phcd1 Off
- 10304 Off
- 10301 Off
- 10302 Off
- 10303 Off
- 10327 Off
- M1034 Off
- HBR1 Off
- HBR2 Off
- HBR3 Off
- HBR4 Off
- HBR5 Off
- HBR6 Off
- HBR7 Off
- HBR8 Off
- HBR9 Off
- HBR11 Off
- HBR12 Off
- HBR10 Off
- HBR13 Off
- SOBFT
- 10321 Off
- 10322 Off
- 10333 Off
- 10324 Off
- 10325 Off
- 10336 Off
- M11001 Off
- M1100b Off
- M1100c Off
- Relationshiphealth statusability to help 1
- 10361 Off
- 10362 Off
- 10363 Off
- 10364 Off
- 10365 Off
- 10366 Off
- 1210d Off
- 1210an Off
- 1210hea Off
- 1210OTH Off
- 1210TIN Off
- 1210NP Off
- 12102 Off
- 12101 Off
- 1210uk Off
- 1210h Off
- 1210v Off
- 1200CAT Off
- 1200OTH Off
- 1200JA Off
- 1200CATRL Off
- 1200OTHER Off
- 1200PT Off
- 1200GLAU Off
- 1200NOP Off
- NOSECON Off
- NOSEEP Off
- NOSELS Off
- NOSESINP Off
- NOSEASG Off
- NOSEOTHSP Off
- NOSENP Off
- THROATDY Off
- TROATL Off
- THROATOTH Off
- 1200BV Off
- 1200LB Off
- THROATHO Off
- THOATSO Off
- THROATNP Off
- 1200GL Off
- 1200CO Off
- 1200PR Off
- 1200IN Off
- M1200 Off
- M1220 Off
- M1230 Off
- MOUTHMas Off
- MOUTHGI Off
- MOUTHULC Off
- MOUTHTOO Off
- MOUTHANY Off
- MOUTHOTH Off
- MOUTHNP Off
- M1240 Off
- M1242 Off
- MOUTHDE Off
- MOUTHUP Off
- MOUTHLO Off
- MOUTHPAR Off
- COPYN Off
- MKMEDP Off
- CPCYN Off
- DPRYN Off
- ICPYN Off
- TURGGP Off
- BESTPAINSC2
- WORSES2
- BESTPAINSC
- WORSESC
- BESTPAINSC3
- WORSESC3
- FACESOBS Off
- SCALE010 Off
- WPSL Off
- WPMA Off
- WPMV Off
- WPAMB Off
- WPIMM Off
- WPTR Off
- WPOTH Off
- WPNP Off
- NVIM Off
- WRP4 Off
- WRP5 Off
- WRP6 Off
- WRP7 Off
- WRP8 Off
- WRP9 Off
- WRPOTH Off
- TKMEDNV Off
- TKMEDLDD Off
- TKMEDD Off
- TKMED23 Off
- TKMEDLT3 Off
- PCTSL Off
- PTXSEN Off
- PTXSEV Off
- PTXSECF Off
- PRDOCC Off
- PTXSEOTH Off
- PRDCONT Off
- WRP1 Off
- WRP2 Off
- WRP3 Off
- PRDINT Off
- PRDFRQ Off
- PHYNOTPT Off
- PHYNOTSTF Off
- NVIG Off
- NVIC Off
- NVIAF Off
- DMIJUV Off
- DMTPII Off
- INSDGFQ Off
- DMODIET Off
- ADMOTH Off
- symphyg Off
- sympfat Off
- symhypog Off
- endopcgr Off
- endopostpra Off
- endorand Off
- endolab Off
- bsrange Off
- bsranptcg Off
- endomonsf Off
- endomoncg Off
- endomonsn Off
- endomonoth Off
- dmNapb Off
- othendopb Off
- enlthyr Off
- intoheatcol Off
- endonp Off
- HEMAANE Off
- HEMABLEED Off
- HEMAHEMO Off
- HEMAINMO Off
- HEMAOTH Off
- HEMANP Off
- SKINITCH Off
- SKINRASH Off
- SKINDRY Off
- SKINSCL Off
- SKINRED Off
- SKINBRU Off
- SKINECCH Off
- SKINPALL Off
- SKINJAU Off
- ADMSELF Off
- ADMSCGF Off
- ADMNURS Off
- SKINNP Off
- m1300 Off
- M1302 Off
- M1306 Off
- M1320 Off
- M1322 Off
- M1324 Off
- M1330 Off
- M1332 Off
- M1334 Off
- M1340 Off
- M1342 Off
- M1350 Off
- WCPYN Off
- IPDMYN Off
- APHYN Off
- SDRBY Off
- SDRSN Off
- SDRCG Off
- SDRPT Off
- SDROTH Off
- TECST Off
- TECCL Off
- WDCLW Off
- WDIRRW Off
- WDPKW Off
- WDDREW Off
- DBFEXD Off
- DBFEX2D Off
- DBFEXEOD Off
- DFEX2WK Off
- DBNFEXWK Off
- DFEXOTH Off
- PDPPRL Off
- PDPARL Off
- LSWRL Off
- endobm Off
- endotv Off
- fbs Off
- LSCDRL Off
- ASCCFR Off
- ASCCFL Off
- Right for
- ASCCFLF
- TRINR Off
- BURRL Off
- LEGHP Off
- LEGHAB Off
- DBFEXRN Off
- DFEXCG Off
- DBFEXPT Off
- DBFEXOT Off
- EXSER Off
- EXSERG Off
- EXSANG Off
- EXSER2 Off
- EXSERG2 Off
- EXSANG2 Off
- SHOV Off
- SHAPRD Off
- SHAPOTH Off
- SHOV2 Off
- SHAPRD2 Off
- SHAPOTH2 Off
- cm length
- cm length2
- DBFTEXRNPT Off
- EXDYN Off
- EXDYN2 Off
- APHYN2 Off
- APHYN3 Off
- Loc3w
- Loc2w
- Loc1w
- Loc4w
- Typew1
- Typew2
- Typew3
- Typw4
- sizw3
- tunnw3
- surrw1
- stomaw1
- surrw1a
- stomaw1a
- surrw3
- surrw3a
- stomaw3
- stomaw3a
- surrw2
- surrw2a
- stomaw2
- stomaw2a
- surrw4
- surrw4a
- stomaw4
- stomaw4a
- statgew2
- statgew3
- Odorw2
- Odorw3
- Edemaw2
- Edemaw3
- appw2
- appw3
- Treatment Ordered_2
- Treatment Ordered_3
- Group10 Off
- draick2 Off
- driack3 Off
- draick4 Off
- colw11 Off
- colw12 Off
- colw31 Off
- colw32 Off
- colw33 Off
- colw34 Off
- colw21 Off
- colw22 Off
- colw23 Off
- colw24 Off
- colw43 Off
- colw44 Off
- ital1u1 Off
- ital1u2 Off
- fsrrepo Off
- frsact Off
- rwgchpt Off
- rwgchcgf Off
- rwgchnur Off
- pulreg1 Off
- pulirreg1 Off
- fsrrespreg Off
- colw41 Off
- colw42 Off
- bpsitly Off
- bpstand Off
- fsrwgrep Off
- fsrwgact Off
- tempaxil Off
- temptymp Off
- pulseappical Off
- pulseradial Off
- pulsebrach Off
- pulsecarot Off
- pulserest Off
- pulsecheyn Off
- pulseactiv Off
- respirirreg Off
- respideath Off
- respaccess Off
- respiapnea Off
- bsckrack Off
- temporal Off
- temprect Off
- chestprad Off
- colw13 Off
- colw14 Off
- consth2 Off
- consthic2 Off
- consth3 Off
- consthic3 Off
- consth4 Off
- consthic4 Off
- chestpyes Off
- chestpainno Off
- consth1 Off
- consthic1 Off
- cpsubstern Off
- cpviselike Off
- dm5lin
- assocwithsoboe Off
- associawactv Off
- associwsweat Off
- cphowreloth Off
- cphowrelrest Off
- cphowrelmeds Off
- cppalarr Off
- cppalpfast Off
- cppalpslow Off
- cppalpfatig Off
- cpedema Off
- cpedemapedal Off
- cpangina Off
- cppostural Off
- cplocalized Off
- cpedempedrig Off
- cpedemapedallef Off
- cpedemasacral Off
- cpedemadepend Off
- cpedemapitt Off
- cpedemanonpitt Off
- cstcramp Off
- cardstclaud Off
- cardstcapref Off
- cstcaprefless Off
- castcaprefgreat Off
- csthsreg Off
- csthsirreg Off
- csthsmurmur Off
- cstpacemak Off
- cpstabreassouclear Off
- breassodwheez Off
- bresddimm Off
- chestpaidull Off
- cpache Off
- cpsharp Off
- brsdabset Off
- brsdsobsoboe Off
- brsdsobonmineff Off
- 14001 Off
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- 1400tva Off
- 14002 Off
- 1400car Off
- 14101 Off
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- 14104 Off
- uroops Off
- uropat Off
- urocare Off
- 14000 Off
- urosn Off
- Radio Button2 Off
- 16100 Off
- 16101 Off
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- O2satur
- O2firesaf Off
- O2sn Off
- O2carefamother Off
- O2cough Off
- O2no Off
- O2yes Off
- O2nonprod Off
- O2noc Off
- O2yesc Off
- O2dys Off
- O2rest Off
- O2dADL Off
- O2sliplo Off
- O2nop Off
- O2yesp Off
- 16other Off
- genibur Off
- genihes Off
- genihema Off
- geniolig Off
- geniurg Off
- geninoc Off
- geniincon Off
- geniuri Off
- genidiap Off
- 16lowna Off
- genicyell Off
- genicamber Off
- genicbr0 Off
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- genicla Off
- geniclo Off
- genised Off
- geniodno Off
- genifol Off
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- geniyes Off
- genino Off
- 1620 Off
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- genmass Off
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- genwart Off
- geninf Off
- gensurg Off
- genprost Off
- gensef Off
- genmeno Off
- genhyst Off
- gendisc Off
- geniodyes Off
- gennp Off
- 1630flat Off
- 17001 Off
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- 1700gross Off
- 1700paral Off
- 1700stu Off
- 1700halluc Off
- 1700psy Off
- 1700oth Off
- 1700np Off
- EFAD TPN Off
- 17003 Off
- EFAD jej Off
- EFAD iv Off
- EFAD pum Off
- EFDA bol Off
- EFDA con Off
- EFA pat Off
- EFDA sn Off
- EFDA car Off
- EFDAoth Off
- EFDAfu Off
- EFDA na Off
- EFDA np Off
- abd pa Off
- ABD dis Off
- ABD hard Off
- ABD soft Off
- ABD asc Off
- ABD ab Off
- ABD oth Off
- ABD bow Off
- ABD other Off
- ABD ten Off
- EFAD Nas Off
- efad gas Off
- EFAD ot Off
- 17101 Off
- 17102 Off
- 17103 Off
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- 17100 Off
- 1720 Off
- gen dis Off
- genbre Off
- genmast Off
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- genles Off
- 1630 other Off
- 1730 Off
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- 1 Oriented Off
- msnp Off
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- psni Off
- psd Off
- psnas Off
- lbm Off
- lbps Off
- lbph Off
- lbf Off
- lbs Off
- urw Off
- sceri Off
- 17403 Off
- ps Off
- ABD pn Off
- pslm Off
- psdp Off
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- psrf Off
- psnh Off
- psue Off
- psir Off
- pse Off
- psep Off
- psea Off
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- msfr Off
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- mscon Off
- msat Off
- msad Off
- mscan Off
- msuns Off
- mstp Off
- mswal Off
- msdec Off
- par Off
- msot Off
- mssh Off
- mswe Off
- mswea Off
- mskp Off
- msother Off
- mshe Off
- mspa Off
- msqua Off
- msoth Off
- msnop Off
- psina Off
- pssi Off
- psnap Off
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- psan Off
- psfat Off
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- psdif Off
- psdis Off
- psdep Off
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- psnp Off
- psade Off
- psdisc Off
- mscom Off
- msamp Off
- FL2 Off
- FL3 Off
- FL7 Off
- FL8 Off
- FL9 Off
- FLA-d Off
- FLb Off
- FLg Off
- FLart Off
- FLdiz Off
- FLhead Off
- FLins Off
- FLanx Off
- FLsob Off
- FLpoor Off
- FLprod Off
- FLheart Off
- FLp Off
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- FL1n Off
- FL4 Off
- FL6 Off
- FL5 Off
- adl o Off
- adl 1 Off
- adl 2 Off
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- 1810 0 Off
- 1810 1 Off
- 18102 Off
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- 19100 Off
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- FL1 Off
- 1910sg Off
- 1910sgp Off
- 1910sgd Off
- 1111910sgp Off
- 1910sgo Off
- 18302 Off
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- adlr Off
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- 1910aw Off
- 1910bw Off
- 1910cnr Off
- 1910do Off
- alleasp Off
- alleggs Off
- alleib Off
- allesulf Off
- allead Off
- alledm Off
- allelod Off
- allepol Off
- alledust Off
- alleother Off
- 20000 Off
- 2000na Off
- 14D1 Off
- 20001 Off
- 20002 Off
- 2010 Off
- 2002 Off
- 2040a Off
- 2040b Off
- 2020 Off
- 2030 Off
- infpat Off
- picccir Off
- ivadacc Off
- int Off
- fo Off
- fa Off
- ule Off
- infiv Off
- perip Off
- mc Off
- gros Off
- tun Off
- nt Off
- ld Off
- lt Off
- cl Off
- pat Off
- rn Off
- cg Off
- ivocc Off
- ivflu Off
- res Off
- red Off
- allerno Off
- iv-i Off
- adp Off
- adc Off
- adrn Off
- adoth Off
- pia Off
- athe Off
- eiv Off
- biood Off
- mva Off
- pn Off
- infna Off
- infcare Off
- rldna Off
- 2100a Off
- 2100b Off
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- 2100d Off
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- smcp Off
- smcpat Off
- smcht Off
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- smpsbp Off
- smoth Off
- oxgava Off
- oxknosw Off
- prr Off
- shan Off
- adi Off
- epci Off
- apn Off
- cih Off
- pmi Off
- sphic Off
- acihsf Off
- dcdmi Off
- dnr Off
- sac Off
- opnc Off
- msr Off
- hsg Off
- asii Off
- gp Off
- fpp Off
- other Off
- pttv Off
- ottv Off
- sttv Off
- ottvist Off
- oxu Off
- oxupe Off
- oufsp Off
- sh Off
- ih Off
- hd Off
- fab Off
- ug Off
- ir Off
- us Off
- nta Off
- pp Off
- mss Off
- ep Off
- ev Off
- sb Off
- adce Off
- sf Off
- ppf Off
- rma Off
- hsd Off
- ppnf Off
- dfc Off
- fpi Off
- dim Off
- imm Off
- ipp Off
- put Off
- cp Off
- ph Off
- sn Off
- ot Off
- st Off
- aid Off
- oth Off
- mfc Off
- nch Off
- oo Off
- mmc Off
- idt Off
- sse Off
- sdi Off
- ncwdo Off
- ddt Off
- eo Off
- no so-cg Off
- nancg Off
- salin Off
- 2x2 Off
- 4x4 Off
- abd Off
- telf Off
- tap Off
- wg Off
- glov Off
- ns Off
- hyd Off
- ks Off
- td Off
- oint Off
- cs Off
- ther Off
- rb Off
- ic Off
- ivsk Off
- ivp Off
- ivt Off
- as Off
- asi Off
- per Off
- et Off
- cid Off
- ip Off
- ss Off
- duo Off
- bs Off
- abs Off
- m2x11 Off
- mt2 Off
- s4x4 Off
- ng Off
- und Off
- ec Off
- ub Off
- op Off
- ow Off
- sat Off
- fol Off
- ls Off
- sc Off
- tc Off
- aa Off
- otth Off
- app Off
- chem Off
- cta Off
- dcfg Off
- hyt Off
- it Off
- syr Off
- glu Off
- es Off
- ft Off
- srk Off
- strk Off
- sstri Off
- is Off
- stst Off
- ta Off
- vg Off
- kl Off
- sr Off
- bath Off
- can Off
- com Off
- smo Off
- prd Off
- egg Off
- hb Off
- hl Off
- efp Off
- neb Off
- oc Off
- pup Off
- pui Off
- or Off
- inj Off
- ivinf Off
- inh Off
- pcbp Off
- fcc Off
- pe Off
- wcd Off
- pai Off
- doc Off
- soa Off
- injr Off
- pt Off
- sup Off
- atu Off
- qc Off
- sd Off
- cht Off
- mep Off
- ncfa Off
- dpd Off
- wdc Off
- dmc Off
- iad Off
- gc Off
- nmd Off
- trc Off
- oca Off
- fc Off
- pfv Off
- oup Off
- uhm Off
- pmh Off
- eim Off
- e911 Off
- puitc Off
- cpdv Off
- dpdp Off
- rp Off
- ko Off
- ipai Off
- iop Off
- iudp Off
- dc Off
- ds Off
- spe Off
- sfcp Off
- ispm Off
- npp Off
- fi Off
- issi Off
- cqm Off
- idc Off
- msw Off
- iicm Off
- ign Off
- ret Off
- mrw Off
- pcd Off
- dccw Off
- ort Off
- epum Off
- meac Off
- pebp Off
- iap Off
- iiph Off
- iccs Off
- ipc Off
- icdb Off
- ipm Off
- ipap Off
- eiad Off
- ipaot Off
- odit Off
- mepc Off
- ttdp Off
- scwc Off
- mr Off
- dn Off
- cef Off
- pcm Off
- si Off
- spi Off
- eplan Off
- oa Off
- nmbs Off
- tg Off
- idp Off
- ipd Off
- icid Off
- igp Off
- ief Off
- ida Off
- nss Off
- api Off
- aps Off
- pst Off
- sib Off
- sdp Off
- ippph Off
- aperi Off
- pf Off
- ap Off
- apv Off
- pa Off
- ans Off
- imb Off
- imt Off
- ewl Off
- acb Off
- mlc Off
- eob Off
- afs Off
- paa Off
- rt Off
- das Off
- got Off
- lsm Off
- dpc Off
- ils Off
- mpb Off
- iao Off
- ihc Off
- mfs Off
- ipcp Off
- tae Off
- iua Off
- tsb Off
- pc Off
- hc Off
- sp Off
- mdc Off
- oh Off
- tpr Off
- ad Off
- awa Off
- psm Off
- gs Off
- wc Off
- lhk Off
- awpc Off
- errand Off
- nlb Off
- fnc Off
- pric Off
- rsf Off
- src Off
- ebc Off
- ppt Off
- gtwa Off
- ebp Off
- eem Off
- nme Off
- nsf Off
- bmt Off
- thm Off
- tt Off
- ism Off
- ephs Off
- irle Off
- isc Off
- atp Off
- mre Off
- te Off
- pas Off
- sfe Off
- pom Off
- sad Off
- isp Off
- fsm Off
- idy Off
- vdt Off
- ar Off
- noc Off
- ldt Off
- mfa Off
- crm Off
- crp Off
- lrp Off
- mrms Off
- sps Off
- acmr Off
- hwi Off
- hdic Off
- psn Off
- dsdc Off
- usb Off
- dcw Off
- saic Off
- dptw Off
- rsm Off
- kss Off
- uhc Off
- hpa Off
- ipi Off
- grp Off
- ftcm Off
- wac Off
- ria Off
- paf Off
- pafi Off
- pwe Off
- ptc Off
- ges Off
- otp Off
- pwdf Off
- pdaf Off
- pdi Off
- pdis Off
- phas Off
- pep Off
- 12100 Off
- allepen Off
- Patient is not diabetic or is bilateral amputee
- mswref Off
- genitonoprob Off
- Urostomy describe skin around stoma Off
- nutrinoprob Off
- O2prod Off
- woraft Off
- woreve Off
- wormor Off
- worsleep Off
- prodsputcol
- fname Off
- Rehabdc1 Off
- mswgwk1
- stgwk2
- stgwk1
- stgwk3
- rhpoor Off
- Clear Form
- E-mail Form
PATIENT CARE COORDINATION
CARE PLAN Reviewed with patient involvementOrder obtainedMedication Form completedreviewedupdated No changeMEDICATION RECORD
Ineffective drug therapySignificant drug interactions
Significant side effectsNon-compliance with drug orders Duplicate drug therapy
Other (specify)M S WSNPhysician AidePT OT STCARE COORDINATION
Explain
Yes No
DME SUPPLIES
IV start kit Underpads size BathbenchChemstrips2x2sIV pole
External catheters
Syringes Cane Quad CaneIV tubing
Urinary bagpouch
COTTON TIP APP4x4s
CommodeAlcohol swabs
Ostomy pouch (brand size)
Special mattress overlayABDs
Angiocatheter size
Cotton tipped applicatorsPeroxide Ostomy wafer (brand size)
Pressure relieving device
Wound cleanserExtension tubingsWound gel
Injection caps
Stoma adhesive tape
Eggcrate
Drain sponges Central line dressing
Skin protectant
Hospital bed
GlovesNon-sterile
Side Rails
Infusion pump Hoyer lift
Sterile Batteries size Enteral feeding pump
Hydrocolloids
Enema suppliesSyringes size
Nebulizer
Kerlix size
Feeding tubeNu-gauze
MEFIX 2X11 YD (EA)
Oxygen concentrator
sizetype Suction machine
SalineNSS
FOLEYCATH SUPPLIES
Suture removal kit Ventilator
Tape
Fr catheter kit
Staple removal kit Walker
(tray bag foley)Transparent dressings
Steri strips
Straight catheter
Wheelchair
Ointment
TRIPLE ANTIBIOTIC 30GR
Irrigation tray
Tens unitSalineNSS
OtherAcetic acid
Other
Page 18 of 20
Patient Name Med Record
wwwpnsystemcom 3058185940 The Outcome and Assessment Information Set (OASIS) is the intellectual property of the Center for Health Services and Policy Research Denver Colorado It is used with permission Expiration date 7312012
10
14
PATIENTCAREGIVER INSTRUCTIONS-TEACHINGCheck all that appliesPatientcaregiver(CG) independent with
Trach care
N oYesWoundDecubitus care
Yes No
Yes N o
Ostomy care Yes
N oYesDiabetic managementcare
N o
N oYesNoYesInsulin administration N oYes
Oxygen useprecautions
Yes N oGlucometer usecalibration N oYes
Use of home medical equipmentdevices
N oYesNutritional managementDiet
NoCaregiver present during the visit Yes
PatientCG educationteaching this visit for
N oYesPatientCG able to understand instructionsteaching
Does the patientCG have a plan when disease symptoms exacerbate (eg when to call the nurseAgency vs emergency 911) N oYes
Comment(s)
SKILLED CARE PROVIDED THIS VISIT
Medication management Administration Oral Injection IV-Infused Inhaled
Foley care Yes N o
Pain ManagementHome prescribed exercisesActivities of Daily LivingPersonal Care
MEDICATION
DISEASE PROCESS COMPLICATIONSSS OFILEAL CONDUITOSTOMY SKINFOOT CAREDIET FLUIDS INFECTION CONTROL
OTHER INSTRUCTIONS GIVEN
N oYesElimination Incontinence management
NEEDS FURTHER TEACHINGExplain
NA NANANANANA
NANANANANANANA
Yes N oPhysician follow up visitsappointments NA
Expected Outcome
DISCHARGE PLANNING DISCUSSEDEXPLAINED Patient unable to perform own Wound Care dueto
Patient unable to InsulineInjection self administration dueto
No SO or CG ablewilling for wound careInsulin-Injection administration at this time
Telfa
Colostomy Supplies
Thermometer
Texas Cath
Red Box (Biohazard)
Betadine Solution
Abd Pads
Duoderm
Sharp Container
Ace band size
Leg Straps Cath
ALCOHOL PREP PADS
DUODERM CFGHY-TAPE 2INSERTION TRAY 5CC
INSULIN SYRINGE ____ CCSYRINGES
Glucometer
MICROPORE TAPE 2
SOFTWICK 4X4
VASELINE GAUZE 3X9
KLING 4
(SOC)
Medication Management Check all that appliesidentified Potential adverse effectsdrug reactionsSG
Skil led Observation AssessmentINJECTION ROUTE_______ SITE _____ MED GIVEN ______________________ DOSE __________ REACTION _____________________________
Foley ChangeCare Patient Educationteaching Wound Care Dressing Change Prep Admin Insulin
StandardUniversal Precautions Followed Aseptic Tech Used Quality Control of Glucometer Performed Sharps Discarded Inside Sharps Container
ProcedureTx welltolerated by Pt
Diabetic Observation Care
Correct handwashing technique followed SG ManagementEvaluation Patients Care Plan No caregiverfamily availablewilling to help patient with care procedures
SG
Pshycological carebehaviour problems prevention NA
SA
LUD
HO
ME
CA
RE
wwwpnsy
stemco
m
3058
1859
40
Orders by discipline (optional) To complete CMS485 (POC)
SN - ORDERS - FREQUENCYDURATION
Page 19 of 20
Patient Name Med Record
wwwpnsystemcom 3058185940 The Outcome and Assessment Information Set (OASIS) is the intellectual property of the Center for Health Services and Policy Research Denver Colorado It is used with permission Expiration date 7312012
21
OTHER
General
Psychiatric
F o l e y Care
REPORT ANY ELEVATIONS IN TEMPERATURE TO THE MD
Wound CareDecubitus
IMPROVE THE PTS ABILITY TO PREVENT OR COPE WITH BREATHING DIFFICULTIES
Asthma Respiratory
INST FOR SS EASY FATIGABILITY DYSPNEA PALPITATIONS ANGINA TACHYCARDIAPALLOR DIZZINESS JAUNDICE AND FEVER INST FOR G I DISTURBANCES ASSESS FOR CENTRALNERVOUS SYSTEM SYMPTOMATOLOGY OBTAIN APPROPRIATE LAB TESTS AND REPORT FINDINGS TO MD ADMINISTER PRESCRIBED INJECTABLE _________________ USING ______ TECHNIQUE
Anemia
Included as reference only your Professional Staff must reviewupdatepersonalizedapprove the orders
INSTRUCT IN PREPARATION amp ADMINISTRATION OF INSULIN INSTRUCT ONSET PEAK ampDURATION OF ACTION OF INSULIN INSTRUCT PROPER DISPOSAL OF SYRINGESNEEDLES NURSE TO MONITOR BLOOD SUGAR WITH GLUCOMETER OR ___________ON __________FREQUENCY ampNOTIFY MD OF ALTERED RESULTS TEACH GLUCOMETER OR __________ PROCEDURE amp INTERPRETING RESULTS
InsulinGlucometer
INST DISEASE PROCESS amp COMMON COMPLICATIONS INST PRESCRIBED DIET amp SHOPPING ADVICE INST SSHYPOHYPERGLYCEMIA amp EMERGENCY PROCEDURES INST GOOD SKIN CARE amp GOOD FOOT CARE DAILY CARE OFTEETH INST DIABETIC CHART INST SampA TESTING amp READING RESULTS INSTRUCT TO CARRY ID THAT INCLUDESINFORMATION REGARDING DIABETIC STATUS NAMES amp DOSAGE OF MEDS amp ACTION TO TAKE IF INSULIN REACTION OCCURS INST IMPORTANCE OF GOOD PERSONAL HEALTH HABITS INCLUDING EXERCISE ADEQUATEREST SLEEP REGULAR MED CHECK-UPS (INCLUDING PODIATRIC OPTHAMOLOGIST amp DENTIST)
DiabetesMellitus
INST PACED ACTIVITY PROGRAM
OBSERVE FOR SS OF DECOMPENSATION SUCH AS INCREASING TACHYCARDIA WSUDDEN ONSET SOB ON MINEXERTION ORTHOPNEA EXTREME ANXIETY PROGRESSIVE CYANOSIS GENERALIZED PALLOR AND DIAPHORESISCHF
INSTRUCT PROPER ADMINISTRATION OF OXYGEN THERAPY INSTRUCT OXYGEN PRECAUTIONSINSTRUCT MAINTENANCE OXYGEN EQUIPMENTOxygen
ASSESS FOR CHEST PAIN TYPE LOCATION INTENSITY DURATION amp FREQUENCY IS PAINMANAGEMENT NOTIFY MD IF PAIN PERSISTS IS GRADUAL PROGRESS ACTIVITY INCREASEINST DISCONTINUE ACTIVITY IF CHEST PAIN DYSPNEA FATIGUE OR PALPITATIONS OCCUR
Angina
PSYCHOLOGICAL ASSESSMENT ASSESS NEUROLOGICAL STATUS IMPLEMENT AND MONITOR BOWEL REGIMEN ampTEACH PROGRAM TO FAMILY SN TO MONITOR TRANQUILIZER EFFECTS GIVEN FOR SEVERE AGITATIONANXIETYEVALUATE FOR WEIGHT LOSS WEIGH PATIENT Q VISIT AND RECORDS WEIGHTS MONITOR LEVEL OFCONSCIOUSNESS ASSESS COORDINATION AND BALANCE PROVIDE EMOTIONAL SUPPORT TO PATIENT ANDFAMILY OBSERVATION AND EVALUATION OF BLADDER ELIMINATION HABITS MANAGEMENT IF INCONTINENCEASSIST FAMILY IN SETTING UP ROUTINE PATIENT-CENTERED AND STRESS THE IMPORTANCE OF ADHERING
Alzheimers
AIDE - ORDERS - FREQUENCYDURATIONTUBSHOWER BATH PERSONAL CARE HAIR COMB SHAMPOO PRN MOUTHDENTURE CARE SKIN CHECK ORAL HYGIENE TPRASSIST TO DRESS ASSIST WITH AMBULATION PREPARE SERVE MEALS GROCERY SHOP WASH CLOTHES LIGHT HOUSEKEEPING ASSIST WITH PERSONAL CARE AND ADLSERRANDS NOTIFY LAST BM IF NONE FOR 3 DAYS FEETNAILS CARE PERI CARE REPORT SIGNIFICANT FINDING TO SN STRAIGHTEN ROOM amp CHANGE LINEN
PT - ORDERS - FREQUENCYDURATIONEVALUATE BALANCE AND COORDINATION EVALUATE ENDURANCE MOBILITY NEUROMUSCULAR RE-EDUCATIONPERFORM PRESCRIBED THERAPEUTIC EXERCISES NOTIFY SIGNIFICANT FINDING TO MDAGENCY BED MOBILITY TRAININGGAIT TRAINING WITH ASSISTIVE DEVICE TEACH HOME MAINTENANCE PROGRAM AND STRENGTHENING EXERCISEEXERCISE BOTH PASSIVE AND ACTIVE EXERCISE REGIMEN TRANSFER TRAINING INSTRUCT IN SAFETY MEASURES FALL PRECAUTIONS
OT - ORDERS - FREQUENCYDURATIONEVALUATE PATIENT AND HOME FOR SAFETY ADL TRAINING PROGRAM MUSCLE RE-EDUCATION BODY IMAGE TRAININGINCREASE RIGHT AND LEFT UPPER EXTREMITIES STRENGTH THERAPEUTIC EXERCISE TO (R) AND (L) HANDINCREASE STRENGTH AND COORDINATION PROPRIOCEPTION AND SENSATION
ST FOR EVALUATION TO PROVIDE ORAL MOTOR EXERCISES INVOLVING LINGUAL AND LABIAL EXERCISES SPEECH ARTICULATION DISORDER TREATMENTIMPROVE SPEECH FACIAL SYMMETRY AND MUSCULATION IMPROVE DYSPHAGIA VOICE DISORDER TREATMENT AURAL REHABILITATION NON-ORAL COMMUNICATION LANGUAGE DISORDER TREATMENT
ST - ORDERS - FREQUENCYDURATION
MSW - ORDERS - FREQUENCYDURATIONMSW FOR ASSESSMENT OF SOCIAL AND EMOTIONAL FACTORS COMMUNITY RESOURCE PLANNINGCOUNSELING REGARDING MANAGEMENTADJUSTMENT TO ILLNESS LONG RANGE PLANNING AND DECISION MAKING
PROVIDE SUPPORTIVE AND RELAXATION THERAPY PROVIDE FAMILY THERAPY ASSESS INTERPERSONALBEHAVIOR ASSIST PATIENT TO DEFINE PROBLEMS amp SOCIAL RELATIONSHIPS GIVE POSITIVE REINFORCEMENTASSIST PATIENT TO VERBALIZE FEELINGS
Anxie ty
INST DISEASE PROCESS AND COMMON COMPLICATIONS INST LOW SODIUM DIET - STRESSING IMPORTANCE OFADHERENCE MONITOR PATIENTS BLOOD PRESSURE CLOSELY AND NOTIFY MD OF ANY SIGNIFICANT CHANGESINSTRUCT PT TO AVOID OVER-THE-COUNTER COLD AND SINUS MEDS AS THEY CONTAIN VASOCONSTRICTORINST OF HYPERTENSIVE CRISIS MONITOR FOR SS OF ORTHOSTATIC HYPOTENSION
Hypertension
ASSESS PSYCHOLOGICAL STATUS PROVIDE SUPPORTIVE THERAPY PROVIDE REMOTIVATION ASSESSINTERPERSONAL BEHAVIOR ASSIST PATIENT TO DEFINE PROBLEMS amp SOCIAL RELATIONSHIPS GIVE POSITIVEREINFORCEMENT ENCOURAGE PATIENT TO PERFORM PERSONAL HYGIENE amp GROOMING ACTIVITIESASSIST PATIENT TO EXPRESS REALISTIC IDEAS amp PLANS ASSIST PATIENT TO VERBALIZE FEELINGS
Depression
INSTRUCT PATIENT IN CONSEQUENT PHYSICAL L IMITATIONS PLANNING AN ADEQUATE LEVEL OF DAILYACTIVITIES TEACH PT RE ARTHRITIS SS OF EXACERBATION TEACH THE IMPORTANCE OF GOOD POSTUREPREVENT TRAUMA TO JOINTS INST PT IN THE USE OF ASSISTIVE DEVICE AS PRESCRIBED
Osteoarthritis
SKILLED OBSERVATIONEVALUATION ASSESS VITAL SINGS amp SS COMPLICATIONSINSTRUCTEVALUATE UNDERSTANDING OF DISEASE PROCESS DETECTING COMPLICATIONSDIETNUTRITIONAL STATUS SAFETY PRECAUTIONEMERGENCY MEASURES MED-REGIMEN
PSYCH ASSESSMENT ASSESS FOR SS OF EPSDETECT AND ALLEVIATE SOMATIZED COMPLAINTSLIMIT SETTING MOTIVATION TECHNIQUES IMAGERY TECHNIQUES
RELAXATION TECHNIQUESGOAL ORIENTED TASKS
FOLEY INSERTION _______FR FOLEY WITH___________cc BALLONCHANGE Q MONTH amp PRN x3 FOR CLOGGED LEAKING OR ACCIDENTAL REMOVALINST DRESSING CHANGES ________________________ MONITOR FOR SS COMPLICATIONS amp NOTIFY MD
INST SS INFECTION
MONITOR STATUS OF WOUND OR DECUBITUS (place) ______________INST INFECTION CONTROL MEASURES
INST GOOD NUTRITION TO FACILITATE HEALINGMEASURE AND RECORD WOUND or DECUBITUS SIZE AT SOC AND AT LEAST WEEKLY THEREAFTEROPEN WOUND CAREDRESSING CLEANSE WOUND WITH ___________ TO RINSE WITH __________ AND APPLY______________ AND PRN
OBSERVE AND RECORD TYPE AND AMOUNT OF DRAINAGE COLOR INFECTION SWELLING REDNESS PAINDE CUB ITUS CAR EDR ESS ING CLEAN SE W OUN D WITH ___________ TO R IN SE WITH __________ AN D APP LY ______________ AN D PR N
TEACH THE PATIENT HOW TO USE A METERED-DOSE INHALER MAINTAIN EFFECTIVE AIRWAY CLEARANCE
EMPHASIZE THE IMPORTANCE OF ADEQUATE DAILY FLUID INTAKE
PROMOTE AN EFFICIENT BREATHING PATTER
INST INFECTION CONTROL amp PULMONARY HYGIENE INST COMPLICATIONS IN CARDIOPULMONARY STATUSINST PREVENTION OF COMPLICATIONS IE AVOID OVER-EXERTION CHILLING CROWDS ETC
INST D ISEASE PROCESS amp MAINTENANCE
INSTRUCT COUGHING DEEP BREATHING EXERCISES INST PATIENT TO MAINTAIN ADEQUATE REST PATTERN
MANAGEMENT AND EVALUATION OF A PATIENT CARE PLAN TEACHING AND TRAINING DISEASE PROCESS SKIN CARE WOUND CAREDRESSING CHANGE DECUBITUS CARE MEDICATION REGIMEN DIETNUTRITIONHYDRATION COMPLICATIONS OF ENT FEEDING AS INDICATED
PAIN CONTROL MEASURES SYMPTOM CONTROL MEASURES SINGSSYMPTOMS OF INFECTION SAFETYPREVENTION OF INJURY EMERGENCY PLANS OXYGEN ADMINISTRATION
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GOALSREHABILITATION POTENTIAL CMS485 (POC)Included as reference only your Professional Staff must reviewupdatepersonalizeapprove the goals
DISCHARGE PLANNING DISCUSSED WITH PATIENT Yes No REHAB POTENTIAL ExcellentPoor Fair Good
SIGNATUREDATES
X DateStaff Completing the OASIS (signaturetitle)
OASIS INFORMATION
Data Entry Date amp Locked Date SubmittedQA Date Reviewed
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SN - GOALSMRMS _________________ WILL EXHIBIT VITAL SIGNS WITHIN ACCEPTABLE RANGE AND STABILIZED DISEASE PROCESSVERBALIZES KNOWLEDGE OF DISEASE MANAGEMENT MEDICATIONS SIDE EFFECTS PRECAUTIONS DIET FLUIDS TREATMENT PROGRAM SS NECESSITATING MEDICAL ATTENTION EMERGENCY CARE
STABILIZATION OF PSYCHOLOGICAL STATUS WITHIN DISEASE LIMITS TO REDUCE THE PATIENTS ANXIETY LEVELDEPRESIONANXIETY CONTROLED TROUGH MED REGIMEN INTERVENTIONS
ANEMIA CONTROLLED THROUGH MED REGIMEN IMPROVED HEMATOLOGIC STATUS
General
Psychiatric
A n e m i aHEALED WOUND WITHOUT INFECTION OR COMPLICATIONS DEMONSTRATE PROPER WOUND CARE
Wound Care
PTSO SHOULD UNDERSTAND THE NATURE SYMPTOMS STAGE AND PROGRESSION OF ALZHEIMERS DISEASEKNOW HOW TO RECOGNIZE PTS OWN STRESS AND WAYS TO PREVENT OR REDUCE IT PROMOTE SOCIAL INTERACTION AS TOLERATED BY THE PATIENT
Decubitus
DEMONSTRATE STRATEGIES TO BE USED DURING A COUGHING EPISODE HELP THE PATIENT IDENTIFY FACTORSTHAT MAY CAUSE ASTHMA ATTACKS OR CONTRIBUTE TO THEMAsthma
SAFELY ADMINISTERS INJECTION COMPREHEND RATIONALE FOR AND IS ABLE TO ROTATE INJECTION SITESCOMPREHEND SAFETY FACTORS IN SYRINGENEEDLE DISPOSALPATIENTCG ABLE TO MONITOR BLOOD SUGAR CORRECTLY WITHOUT ASSISTANCEABLE TO NOTIFY MD OF ALTEREDOUT OF RANGE RESULTS
InsulinGlucometer
DISCHARGE PT WHEN BLOOD SUGARS ARE WITHIN THE NORMAL FOR PATIENT RANGEKNOW THE ACCEPTABLE RANGE FOR BLOOD SUGAR LEVEL COMPLY WITH DIET RESTRICTIONS Diabetes
MellitusRETURN TO SELF-MANAGEMENT OF HEALED FRACTURED
FractureKNOW ABOUT SIGNS SYMPTOMS AND PRECIPITATING CAUSES OF CHF KNOW HOW TO TAKE THE PULSE AND KNOWTO CONSULT THE DOCTOR BEFORE CONTINUING MEDICATION IF THE PULSE RHYTHM CHANGES KNOW TOA V O I D S M O K I N G A N D S M O K Y E N V I R O N M E N T S A N D P E R S O N S W I T H I N F E C T I O N S E S P E C I A L L Y R E S P I R A T O R Y I N F E C T I O N S
CHF
UNDERSTAND THAT HYPERTENSION IS A CHRONIC DISEASE REQUIRING LIFE LONG TREATMENT EXHIBIT BLOODPRESSURE READINGS CONSISTENTLY WITHIN NORMAL OR SPECIFIED RANGE DEMONSTRATE ADHERENCE TO ALOW-SALT LOW-FAT DIET
Hypertension
HELP THE PATIENT ACHIEVE PAIN RELIEVE AND REDUCE ANGINA EPISODES UNDERSTAND THE CAUSE OFANGINA PECTORIS AND POSSIBLE PRECIPITATING FACTORS FOR AN ATTACK IDENTIFY PERSONAL STRESSORSTHAT MAY CONTRIBUTE TO THE PROBLEM AND BEGIN ELIMINATING OR MINIMIZING THEM KNOW WAYS TOREDUCE THE FREQUENCY OF ANGINA EPISODES
Angina
HEALED DECUBITUS WITHOUT INFECTION OR COMPLICATIONS DEMONSTRATE PROPER DECUBITUS CARE
Alzheimers
UNDERSTAND SS OF BRONCHITIS OR OTHER RESPIRATORY INFECTION AND DISEASE EXACERBATIONUNDERSTAND THE DANGERS OF SMOKING AIR AND CHEMICAL POLLUTANTS AND RESPIRATORY INFECTIONUNDERSTAND AND PRACTICE COUGHING AND DEEP-BREATHING EXERCISES
Respiratory
DAILY COMPLIANCE WCATHETER CARE DECREASE RISK OF URINARY INFECTIONCatheter
INCREASED PAIN RELIEF INCREASED STRENGTH AND ENDURANCE COMPREHEND AND DEMONSTRATE HOME EXERCISEOsteoarthritis
AIDE - GOALS
GAIT PATTERN ENDURANCE STRENGTH AND BALANCE WILL IMPROVE AND PATIENT WILL DEMONSTRATECORRECT BODY MECHANICS WIN 4-6 WKS PTCG WILL COMPREHEND AND DEMONSTRATE HOME EXERCISEPROGRAM WITHIN 4-6 WKS
FAIR-TO BE ABLE TO CARRY OUT MINIMAL ADLS WITH AVAILABLE HOME SUPPORTWILL NOT BE ABLE TO CARRY OUT ADLS WITHOUT MAXIMUM SUPPORT
RETURN TO INDEPENDENT AMBULATION BE SAFE IN SELF CAREPATIENT WILL BE ABLE TO FUNCTION WITH ASSISTANCE OF CAREGIVERWITHIN HESHE CURRENT LIMITATIONS AT HOME
PATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HISHER CURRENT LIMITATIONS AT HOME
PT - GOALS
GOOD RETURN TO PREVIOUS LEVEL OF ADLS INDEPENDENTLY
GAIT PATTERN ENDURANCE STRENGTH AND BALANCE WILL IMPROVE AND PT WILL DEMONSTRATECORRECT BODY MECHANICS WITHIN _____ WEEKS
PATIENT WILL EXPERIENCE A DECREASE IN PAIN
PTCG WILL COMPREHEND AND DEMONSTRATE HOME EXERCISEPROGRAM WITHIN _____ WEEKS
OT PATIENT WILL EXHIBIT IMPROVEMENT IN COPING IN ADLSIADLS MUSCLE USEMOTORCOORDINATIONNEURO RESPONSEUSE OF ORTHOTIC SPLINTING ANDOR EQUIPMENT
OT - GOALS
PATIENT WILL DEMONSTRATE FUNCTIONAL COMMUNICATIONS EXHIBIT MAXIMUM VERBAL AND SENTENCEFORMULATION AND COMPREHENSION WITHIN DISEASE LIMITS WITHIN _____ WEEKS
ST - GOALS
PATIENT WILL DEMONSTRATE APPROPRIATE USE OF FUNCTIONAL VERBALNON-VERBALCOMMUNICATIONS SYSTEMS WITHIN _____ WEEKS
PATIENT WILL DEMONSTRATE IMPROVED READINGWRITING USE OF GESTURESNUMBERS WITHIN _____ WEEKS
PATIENT WILL DEMONSTRATE IMPROVED SWALLOWINGCHEWINGORALMOTOR CONTROL WITHIN _____ WEEKS
PATIENT WILL HAVE ADEQUATE SUPPORT TO REMAIN IN HOME WITH ASSISTANCE OF COMMUNITYRESOURCES FOR FINANCIAL TRANSPORTATION AND PERSONAL CARE ASSISTANCE WITHIN _____ WEEKS
MSW - GOALSPSYCHOSOCIAL EVALUATION WILL BE PERFORMED PTCG WILL BE COUNSELED REGARDING MANAGEMENTamp ADJUSTMENT TO ILLNESS LONG TERM PLANNING AND DECISION MAKING APPROPRIATE COMMUNITYRESOURCE REFERRALS WILL BE MADE
WILL DISCHARGE THE PATIENT WITHIN 60 DAYS WHEN PATIENT ANDORCAREGIVER ISARE ABLE TO DEMONSTRATE KNOWLEDGE OF DISEASE MANAGEMENT SS COMPLICATIONSPATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HISHER CURRENT LIMITATION AT HOME
ABLE TO REMAIN IN HOMERESIDENCEALF WITH ASSISTANCE OF PRIMARY CAEGIVERSUPPORT AT HOMEABLE TO UNDERSTAND MEDICATION REGIMEN AND CARE RELATED TO HISHER DISEASEWILL BE DISCHARGE WHEN MAXIMUM FUNCTIONAL POTENTIAL REACHED
Patient Name Med Record
wwwpnsystemcom 3058185940 The Outcome and Assessment Information Set (OASIS) is the intellectual property of the Center for Health Services and Policy Research Denver Colorado It is used with permission Expiration date 7312012
XPatient Signature if required optional if itinerary is used
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- OASIS_C_SOC
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- PT ID PERFORMED VIA NAME DOB FACE RECOGNITION AND ADDRESS BEFORE SERVICE PROVIDED Off
- TIME IN
- TIME OUT
- Agency Name SALUD HOME CARE INC
- Phone 305-555-5555
- Employees NameTitle Completing the OASIS
- who has signed the plan of care
- Physician name
- Address 1
- Address 2
- Phone Number
- Address 1_2
- Address 2_2
- Patient Phone
- Reason
- Name
- Other Physician if any
- Phone_2
- Address 1_3
- Address 2_3
- Phone Number_2
- REFERRAL SOURCE if not from Primary Physician
- undefined_6
- Phone_3
- Fax
- Evacuation Form needed Emergency Reg 1
- Evacuation Form needed Emergency Reg 2
- EMERGENCY CONTACT
- Address
- Comments 1
- Comments 2
- Phone_4
- Relationship
- OTHER
- Comment 1
- Comment 2
- 11 Other specify
- a
- b
- 7 Other specify
- c
- d
- e
- f
- a_2
- b_2
- d_2
- e_2
- f_2
- a_3
- b_3
- d_3
- Comment if needed 1
- Comment if needed 2
- a_4
- a_5
- a_6
- Date 23
- undefined_7
- undefined_8
- b_4
- b_5
- b_6
- Date_2
- undefined_9
- undefined_10
- Date_3
- undefined_11
- undefined_12
- d_4
- d_5
- d_6
- Date_4
- undefined_13
- undefined_14
- Date_5
- undefined_15
- undefined_16
- Date_6
- undefined_17
- undefined_18
- 12 1
- 12 2
- Date_7
- undefined_19
- undefined_20
- Date_8
- undefined_21
- undefined_22
- MAIN REASON FOR HOME HEALTH CARE 1
- MAIN REASON FOR HOME HEALTH CARE 2
- Fractures site
- Surgeries site
- Cancer site
- Open Wound site
- Decubitus site
- Other specify
- Other
- Pending or Needed
- Yes Number of times
- Reason s Dates
- MobilityAmbulatory devices used
- Other specify_2
- undefined_23
- Comments if needed 1
- Comments if needed 2
- Comments if needed 3
- Comments if needed 4
- undefined_24
- Name_2
- Phone number if different from patient
- Relationshiphealth statusability to help 2
- Any paid help explain
- Specify 1
- Specify 2
- Specify 3
- Any ears surgeryprocedure
- Date_9
- Otherspecify 1
- Otherspecify 2
- Other agencies involved in care 1
- Other agencies involved in care 2
- 1
- 2
- Other_2
- Infections
- Cataract surgery Site
- Date_10
- Other eyes surgery Site
- Date_11
- explain 1
- explain 2
- Any nose surgery
- Date_12
- Other specify_3
- 1_2
- 2_2
- MassesTumors site
- Lesions explain
- Any surgeryprocedure
- Other specify 1
- Other specify 2
- Other specify 3
- Date_13
- Other specify_4
- No Problem
- Medication
- Other_3
- Pain control treatmentmeds Side effect mark
- Other_4
- Is there a regular pattern to the pain explain
- Other_5
- Comment
- What was the outcome
- Type II OnsetExacerbation date
- DietOral control specify
- INSULIN dosage frequency scale explain
- 1_3
- 2_3
- Since
- Other_6
- A1c
- BS
- mgdL DateTime
- Blood sugar ranges
- site 1Location site
- site 2Location site
- site 3Location site
- Frequency
- Other_7
- site 1New Onset Exacerbation
- site 2New Onset Exacerbation
- site 3New Onset Exacerbation
- Able to use Glucometer
- site 1Present level 010
- site 2Present level 010
- site 3Present level 010
- Diabetes Management Problems explain 1
- Diabetes Management Problems explain 2
- Other Endocrine problems
- site 1Occasional y Cont Intermittent Frequency Frequently
- site 2Occasional y Cont Intermittent Frequency Frequently
- site 3Occasional y Cont Intermittent Frequency Frequently
- site 1Pain type ach ng burn ng rad ating neura gia etc
- site 2Pain type ach ng burn ng rad ating neura gia etc
- site 3Pain type ach ng burn ng rad ating neura gia etc
- Anemia specify type if known
- site 1Feeling of pain internal external acute chronic
- site 2Feeling of pain internal external acute chronic
- site 3Feeling of pain internal external acute chronic
- site 1Pain is worse morning
- site 2Pain is worse morning
- site 3Pain is worse morning
- Immunodeficiency problems explain
- Other 1
- Other 2
- Other_8
- explain 1_2
- explain 2_2
- explain 3
- explain 4
- Other specify 1_2
- Other specify 2_2
- undefined_25
- undefined_26
- undefined_27
- undefined_28
- undefined_29
- undefined_30
- undefined_31
- undefined_32
- undefined_33
- undefined_34
- undefined_35
- undefined_36
- M1310 Pressure Ulcer Length Longest length headtotoe
- undefined_37
- cm
- greatest width perpendicular to the length
- M1314 Pressure Ulcer Depth Depth of the same pressure ulcer from
- cm_2
- visible surface to the deepest area
- undefined_38
- cm_3
- 1_4
- 2_4
- 3_2
- Other_9
- 4_2
- Caregiver name
- Other_10
- cant integument findings
- Observation
- Observation_2
- Caregiver name_2
- Other_11
- Wound cleaned with specify
- Wound irrigated with specify
- 1 Size
- cm width
- Wound packed with specify
- Location
- Other_12
- Wound dressingcover applied specify
- 2 Size
- cm width_2
- Comments 1_2
- Comments 2_2
- Location_2
- Other_13
- Sizecm LengthxWidthxDepth
- Sizecm LengthxWidthxDepth_2
- Diagram 4Sizecm LengthxWidthxDepth
- Tunneling Undermining cm
- Tunneling Undermining cm_2
- Diagram 4Tunneling Undermining cm
- Stage IIIIIIIV pressure uIcers only
- Diagram 4Stage IIIIIIIV pressure uIcers only
- Odor Fool normal etc
- Diagram 4Odor Fool normal etc
- Edema pedal sacral p tting etc
- Diagram 4Edema pedal sacral p tting etc
- Appearance of the Wound Bed
- Diagram 4Appearance of the Wound Bed
- Treatment Ordered
- Diagram 4Treatment Ordered
- Other_14
- Other_15
- Other_16
- Other_17
- Yes 1
- Yes 2
- Yes 3
- Height
- Weight
- Radiating to
- GainLoss
- lb X
- Frequencyduration
- Sittinglying R
- L
- Standing R
- L_2
- Medication_2
- Temperature
- Other_18
- Apical
- Brachial
- Radial
- Carotid
- Dependent
- Pitting 1234
- Respirations
- Site
- Cramps site
- Disease Management Problems explain
- Right Upper
- Right
- Right Lower
- 1_5
- 2_6
- 3_3
- Left
- Left Upper
- Left Lower
- Pacemaker Date
- Last date checked
- SOB on minimal effortwalk
- Type
- fy
- Other Prob 1
- Other Prob 2
- O2
- Trach sizetype
- CaregiverfamilyOther
- Yes explain 1
- Yes explain 2
- Other_19
- Comments 1_3
- Comments 2_3
- Increase fluids
- Restrict fluids
- Frequency_2
- Amount
- Yes describe 1
- Yes describe 2
- Frequency_3
- Other 1_2
- Other 2_2
- Nocturia x
- Bowel Off
- undefined_52
- Diapersother
- Other_20
- No
- 2TOTAL
- Urinary Catheter Type
- Last changed on
- Foley inserted date
- with
- Inflated balloon with
- Irrigation solution Type specify
- Amount_2
- mL Frequency
- Returns
- No_2
- 1_6
- 2_7
- Describe at risk intervention and plan 1
- Describe at risk intervention and plan 2
- Describe at risk intervention and plan 3
- DischargeDrainage describe
- Lesions
- Blisters
- Masses
- Cysts
- Wart
- Other specify_5
- Surgical alteration
- Prostate problem BPH TURP Date
- undefined_53
- undefined_54
- Selftesticular exam Frequency
- Hysterectomy Date
- undefined_55
- undefined_56
- Date last PAP
- undefined_57
- undefined_58
- Results
- Breast selfexam frequency
- Mastectomy R L Date
- undefined_59
- undefined_60
- Other specify_6
- Last BM
- Diarrhea Frequency
- Bowel regimeprogram
- Incontinence Off
- Urinary Off
- Diapersother_2
- Other_21
- te describe skin around stoma
- Ileostomycolostomy s 2
- Ileostomycolostomy s 3
- Ileostomycolostomy s 4
- Ileostomycolostomy s 5
- Headache Location
- Frequency_4
- Other_22
- Migraine Frequency
- Site_2
- Weakness UE LE Location
- Other specify_7
- Site_3
- IV
- Pump typespecify
- Hand grips Equal Unequal specify
- Feedings Type amtrate
- Strong Weak specify
- Psychotropic drug use specify
- Flush Protocol amtspecify
- DoseFrequency
- Other_23
- Other specify 1_3
- Other specify 2_3
- DressingSite care specify 1
- DressingSite care specify 2
- Interventions instructionsComments 1
- Interventions instructionsComments 2
- Following Un
- versalStandard precautions
- NA
- No Problem_2
- Pain Frequency
- Abdominal girth
- Bowel sounds active absent hypo hyperactive x
- 3 Forgetful Off
- 4 Depressed Off
- 6 Lethargic Off
- 5 Disoriented Off
- 7 Agitated Off
- 2 Comatose
- 8 Other Off
- Forgetful at times Off
- Irritable Off
- Anxious Off
- Alert Off
- Describe 1
- Describe 2
- undefined_61
- Needs interpreter
- Comments 1_4
- Comments 2_4
- Higher Educational Level
- Fracture location
- Swollen painful joints specify
- Explain
- Contractures Joint
- Spiritual resource
- Location_3
- Phone No
- Atrophy
- Other_27
- Explain 1
- Explain 2
- Decreased ROM
- Paresthesia
- Weakness
- Other_28
- Inappropriate followthrough in past
- Amputation BKAKUE RL specify 1
- Amputation BKAKUE RL specify 3
- Amputation BKAKUE RL specify 4
- Treatment
- Treatment_2
- Other specify 1_4
- Other specify 2_4
- History of Falls past 3 months 12 falls M1032
- V s on Status Poor w or w o glasses M1200
- Vision Status Poor Legally blind M1200
- Gait and Balance Balance problem while standing
- Gait and Ba ance Balance problem while walking
- Gait and Balance Decreased muscular coordination
- Pred spos ng D seases 12 present
- Predisposing D seases 3 or more present
- Equipment Issues Oxygen tubing
- 1Row1
- PlanComments 1
- PlanComments 2
- Comment_2
- undefined_62
- b Ambulation
- c Transfer
- DOther specify
- 7Independent in home 1
- 7Independent in home 2
- Other 1_3
- Other 2_3
- Typebrand
- Size
- Gauge
- Length
- Insertion site
- Insertion date
- Flush solution
- Frequency_5
- Injection cap change frequency
- Dressing change frequency
- Other_29
- Siteskin condition
- External catheter length
- OtherComment
- fluid overload Other
- Circumference of arm
- Huber gaugelength
- Yes date
- Last flushed date
- Siteskin condition_2
- Infusion solution typevolumerate
- Dressing
- OtherComment 1
- OtherComment 2
- Drug Name
- Dose
- Route
- Frequency_6
- Duration of therapy
- Drug Name_2
- Dose_2
- Route_2
- Frequency_7
- Duration of therapy_2
- CommentPlan 1
- CommentPlan 2
- Pump type specify
- Other_30
- Lab draws
- Infusion care provided during visit 1
- Infusion care provided during visit 2
- Infusion care provided during visit 3
- Antibiotic therapy
- 1_7
- 2_8
- Other_31
- Removing line date if know
- BraceOrthotics specify 1
- BraceOrthotics specify 2
- BraceOrthotics specify 3
- Needs specify 1
- Needs specify 2
- Oxygen HME Co
- Prosthesis RUE RLE LUELLEOther
- HME Rep
- Grab bars BathroomOther
- Hospital bed Semielec Crank Spec
- Other_32
- NA_2
- Phone_5
- n care
- PlanComments
- N
- Other_33
- undefined_63
- Physical Therapy Total visits
- Speech Therapy Total visits
- visits
- Other Therapy Total visits
- Patient is not assessed to be at risk for falls
- No pain identified
- Patient has no pressure ulcers with need for moist wound healing
- O
- Noncompliance with drug orders
- Expected Outcome
- Patient unable to perform own Wound Care due
- Pat
- to
- Abd Pads Off
- Underpads size
- undefined_68
- Special mattress overlay
- Angiocatheter size
- Ostomy pouch brand size
- Pressure relieving device
- Ostomy wafer brand size
- undefined_69
- SYRINGES
- Batteries size
- Skin protectant
- Glucometer
- Hydrocolloids
- undefined_70
- FOLEYCATH SUPPLIES
- Syringes size
- size
- Oxygen concentrator
- Feeding tube
- Ointment
- Acetic acid
- Other 1_4
- Other 2_4
- Other 3
- Tens unit
- KLING 4
- Other 1_5
- Other 2_5
- Other 3_2
- PatientCG educationteaching this visit for
- MEDICATION Off
- DISEASE PROCESS COMPLICATIONS Off
- undefined_71
- SS OF Off
- ILEAL CONDUITOSTOMY Off
- DIET FLUIDS Off
- undefined_72
- undefined_73
- SKINFOOT CARE Off
- INFECTION CONTROL Off
- OTHER INSTRUCTIONS GIVEN
- Caregiver present during the visit
- NEEDS FURTHER TEACHING Off
- No_3
- Skilled Observation Assessment
- ent Educat
- Wound Care Dress
- Diabetic Observation Care
- Correct handwashing technique followed SG 1
- Correct handwashing technique followed SG 2
- Correct handwashing technique followed SG 3
- Correct handwashing technique followed SG 4
- 21 Included as reference only your Professional Staff must reviewupdatepersonalizedapprove the orders
- SN ORDERS FREQUENCYDURATION
- S COMPLICATIONS
- TH GLUCOMETER OR
- ON
- TEACH GLUCOMETER OR
- NSERTION
- TH
- INST DRESSING CHANGES
- MONITOR STATUS OF WOUND OR DECUBITUS place
- ADMINISTER PRESCRIBED INJECTABLE
- USING
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- TH_3
- AND APPLY
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- DE ORDERS FREQUENCYDURATION
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- Included as reference only your Professional Staff must reviewupdatepersonalizeapprove the goals 22
- MRMS
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- symphyg Off
- sympfat Off
- symhypog Off
- endopcgr Off
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- Right for
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- glov Off
- ns Off
- hyd Off
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- td Off
- oint Off
- cs Off
- ther Off
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- ic Off
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- tc Off
- aa Off
- otth Off
- app Off
- chem Off
- cta Off
- dcfg Off
- hyt Off
- it Off
- syr Off
- glu Off
- es Off
- ft Off
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- strk Off
- sstri Off
- is Off
- stst Off
- ta Off
- vg Off
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- sr Off
- bath Off
- can Off
- com Off
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- prd Off
- egg Off
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- hl Off
- efp Off
- neb Off
- oc Off
- pup Off
- pui Off
- or Off
- inj Off
- ivinf Off
- inh Off
- pcbp Off
- fcc Off
- pe Off
- wcd Off
- pai Off
- doc Off
- soa Off
- injr Off
- pt Off
- sup Off
- atu Off
- qc Off
- sd Off
- cht Off
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- ncfa Off
- dpd Off
- wdc Off
- dmc Off
- iad Off
- gc Off
- nmd Off
- trc Off
- oca Off
- fc Off
- pfv Off
- oup Off
- uhm Off
- pmh Off
- eim Off
- e911 Off
- puitc Off
- cpdv Off
- dpdp Off
- rp Off
- ko Off
- ipai Off
- iop Off
- iudp Off
- dc Off
- ds Off
- spe Off
- sfcp Off
- ispm Off
- npp Off
- fi Off
- issi Off
- cqm Off
- idc Off
- msw Off
- iicm Off
- ign Off
- ret Off
- mrw Off
- pcd Off
- dccw Off
- ort Off
- epum Off
- meac Off
- pebp Off
- iap Off
- iiph Off
- iccs Off
- ipc Off
- icdb Off
- ipm Off
- ipap Off
- eiad Off
- ipaot Off
- odit Off
- mepc Off
- ttdp Off
- scwc Off
- mr Off
- dn Off
- cef Off
- pcm Off
- si Off
- spi Off
- eplan Off
- oa Off
- nmbs Off
- tg Off
- idp Off
- ipd Off
- icid Off
- igp Off
- ief Off
- ida Off
- nss Off
- api Off
- aps Off
- pst Off
- sib Off
- sdp Off
- ippph Off
- aperi Off
- pf Off
- ap Off
- apv Off
- pa Off
- ans Off
- imb Off
- imt Off
- ewl Off
- acb Off
- mlc Off
- eob Off
- afs Off
- paa Off
- rt Off
- das Off
- got Off
- lsm Off
- dpc Off
- ils Off
- mpb Off
- iao Off
- ihc Off
- mfs Off
- ipcp Off
- tae Off
- iua Off
- tsb Off
- pc Off
- hc Off
- sp Off
- mdc Off
- oh Off
- tpr Off
- ad Off
- awa Off
- psm Off
- gs Off
- wc Off
- lhk Off
- awpc Off
- errand Off
- nlb Off
- fnc Off
- pric Off
- rsf Off
- src Off
- ebc Off
- ppt Off
- gtwa Off
- ebp Off
- eem Off
- nme Off
- nsf Off
- bmt Off
- thm Off
- tt Off
- ism Off
- ephs Off
- irle Off
- isc Off
- atp Off
- mre Off
- te Off
- pas Off
- sfe Off
- pom Off
- sad Off
- isp Off
- fsm Off
- idy Off
- vdt Off
- ar Off
- noc Off
- ldt Off
- mfa Off
- crm Off
- crp Off
- lrp Off
- mrms Off
- sps Off
- acmr Off
- hwi Off
- hdic Off
- psn Off
- dsdc Off
- usb Off
- dcw Off
- saic Off
- dptw Off
- rsm Off
- kss Off
- uhc Off
- hpa Off
- ipi Off
- grp Off
- ftcm Off
- wac Off
- ria Off
- paf Off
- pafi Off
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- ptc Off
- ges Off
- otp Off
- pwdf Off
- pdaf Off
- pdi Off
- pdis Off
- phas Off
- pep Off
- 12100 Off
- allepen Off
- Patient is not diabetic or is bilateral amputee
- mswref Off
- genitonoprob Off
- Urostomy describe skin around stoma Off
- nutrinoprob Off
- O2prod Off
- woraft Off
- woreve Off
- wormor Off
- worsleep Off
- prodsputcol
- fname Off
- Rehabdc1 Off
- mswgwk1
- stgwk2
- stgwk1
- stgwk3
- rhpoor Off
- Clear Form
- E-mail Form
Orders by discipline (optional) To complete CMS485 (POC)
SN - ORDERS - FREQUENCYDURATION
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Patient Name Med Record
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21
OTHER
General
Psychiatric
F o l e y Care
REPORT ANY ELEVATIONS IN TEMPERATURE TO THE MD
Wound CareDecubitus
IMPROVE THE PTS ABILITY TO PREVENT OR COPE WITH BREATHING DIFFICULTIES
Asthma Respiratory
INST FOR SS EASY FATIGABILITY DYSPNEA PALPITATIONS ANGINA TACHYCARDIAPALLOR DIZZINESS JAUNDICE AND FEVER INST FOR G I DISTURBANCES ASSESS FOR CENTRALNERVOUS SYSTEM SYMPTOMATOLOGY OBTAIN APPROPRIATE LAB TESTS AND REPORT FINDINGS TO MD ADMINISTER PRESCRIBED INJECTABLE _________________ USING ______ TECHNIQUE
Anemia
Included as reference only your Professional Staff must reviewupdatepersonalizedapprove the orders
INSTRUCT IN PREPARATION amp ADMINISTRATION OF INSULIN INSTRUCT ONSET PEAK ampDURATION OF ACTION OF INSULIN INSTRUCT PROPER DISPOSAL OF SYRINGESNEEDLES NURSE TO MONITOR BLOOD SUGAR WITH GLUCOMETER OR ___________ON __________FREQUENCY ampNOTIFY MD OF ALTERED RESULTS TEACH GLUCOMETER OR __________ PROCEDURE amp INTERPRETING RESULTS
InsulinGlucometer
INST DISEASE PROCESS amp COMMON COMPLICATIONS INST PRESCRIBED DIET amp SHOPPING ADVICE INST SSHYPOHYPERGLYCEMIA amp EMERGENCY PROCEDURES INST GOOD SKIN CARE amp GOOD FOOT CARE DAILY CARE OFTEETH INST DIABETIC CHART INST SampA TESTING amp READING RESULTS INSTRUCT TO CARRY ID THAT INCLUDESINFORMATION REGARDING DIABETIC STATUS NAMES amp DOSAGE OF MEDS amp ACTION TO TAKE IF INSULIN REACTION OCCURS INST IMPORTANCE OF GOOD PERSONAL HEALTH HABITS INCLUDING EXERCISE ADEQUATEREST SLEEP REGULAR MED CHECK-UPS (INCLUDING PODIATRIC OPTHAMOLOGIST amp DENTIST)
DiabetesMellitus
INST PACED ACTIVITY PROGRAM
OBSERVE FOR SS OF DECOMPENSATION SUCH AS INCREASING TACHYCARDIA WSUDDEN ONSET SOB ON MINEXERTION ORTHOPNEA EXTREME ANXIETY PROGRESSIVE CYANOSIS GENERALIZED PALLOR AND DIAPHORESISCHF
INSTRUCT PROPER ADMINISTRATION OF OXYGEN THERAPY INSTRUCT OXYGEN PRECAUTIONSINSTRUCT MAINTENANCE OXYGEN EQUIPMENTOxygen
ASSESS FOR CHEST PAIN TYPE LOCATION INTENSITY DURATION amp FREQUENCY IS PAINMANAGEMENT NOTIFY MD IF PAIN PERSISTS IS GRADUAL PROGRESS ACTIVITY INCREASEINST DISCONTINUE ACTIVITY IF CHEST PAIN DYSPNEA FATIGUE OR PALPITATIONS OCCUR
Angina
PSYCHOLOGICAL ASSESSMENT ASSESS NEUROLOGICAL STATUS IMPLEMENT AND MONITOR BOWEL REGIMEN ampTEACH PROGRAM TO FAMILY SN TO MONITOR TRANQUILIZER EFFECTS GIVEN FOR SEVERE AGITATIONANXIETYEVALUATE FOR WEIGHT LOSS WEIGH PATIENT Q VISIT AND RECORDS WEIGHTS MONITOR LEVEL OFCONSCIOUSNESS ASSESS COORDINATION AND BALANCE PROVIDE EMOTIONAL SUPPORT TO PATIENT ANDFAMILY OBSERVATION AND EVALUATION OF BLADDER ELIMINATION HABITS MANAGEMENT IF INCONTINENCEASSIST FAMILY IN SETTING UP ROUTINE PATIENT-CENTERED AND STRESS THE IMPORTANCE OF ADHERING
Alzheimers
AIDE - ORDERS - FREQUENCYDURATIONTUBSHOWER BATH PERSONAL CARE HAIR COMB SHAMPOO PRN MOUTHDENTURE CARE SKIN CHECK ORAL HYGIENE TPRASSIST TO DRESS ASSIST WITH AMBULATION PREPARE SERVE MEALS GROCERY SHOP WASH CLOTHES LIGHT HOUSEKEEPING ASSIST WITH PERSONAL CARE AND ADLSERRANDS NOTIFY LAST BM IF NONE FOR 3 DAYS FEETNAILS CARE PERI CARE REPORT SIGNIFICANT FINDING TO SN STRAIGHTEN ROOM amp CHANGE LINEN
PT - ORDERS - FREQUENCYDURATIONEVALUATE BALANCE AND COORDINATION EVALUATE ENDURANCE MOBILITY NEUROMUSCULAR RE-EDUCATIONPERFORM PRESCRIBED THERAPEUTIC EXERCISES NOTIFY SIGNIFICANT FINDING TO MDAGENCY BED MOBILITY TRAININGGAIT TRAINING WITH ASSISTIVE DEVICE TEACH HOME MAINTENANCE PROGRAM AND STRENGTHENING EXERCISEEXERCISE BOTH PASSIVE AND ACTIVE EXERCISE REGIMEN TRANSFER TRAINING INSTRUCT IN SAFETY MEASURES FALL PRECAUTIONS
OT - ORDERS - FREQUENCYDURATIONEVALUATE PATIENT AND HOME FOR SAFETY ADL TRAINING PROGRAM MUSCLE RE-EDUCATION BODY IMAGE TRAININGINCREASE RIGHT AND LEFT UPPER EXTREMITIES STRENGTH THERAPEUTIC EXERCISE TO (R) AND (L) HANDINCREASE STRENGTH AND COORDINATION PROPRIOCEPTION AND SENSATION
ST FOR EVALUATION TO PROVIDE ORAL MOTOR EXERCISES INVOLVING LINGUAL AND LABIAL EXERCISES SPEECH ARTICULATION DISORDER TREATMENTIMPROVE SPEECH FACIAL SYMMETRY AND MUSCULATION IMPROVE DYSPHAGIA VOICE DISORDER TREATMENT AURAL REHABILITATION NON-ORAL COMMUNICATION LANGUAGE DISORDER TREATMENT
ST - ORDERS - FREQUENCYDURATION
MSW - ORDERS - FREQUENCYDURATIONMSW FOR ASSESSMENT OF SOCIAL AND EMOTIONAL FACTORS COMMUNITY RESOURCE PLANNINGCOUNSELING REGARDING MANAGEMENTADJUSTMENT TO ILLNESS LONG RANGE PLANNING AND DECISION MAKING
PROVIDE SUPPORTIVE AND RELAXATION THERAPY PROVIDE FAMILY THERAPY ASSESS INTERPERSONALBEHAVIOR ASSIST PATIENT TO DEFINE PROBLEMS amp SOCIAL RELATIONSHIPS GIVE POSITIVE REINFORCEMENTASSIST PATIENT TO VERBALIZE FEELINGS
Anxie ty
INST DISEASE PROCESS AND COMMON COMPLICATIONS INST LOW SODIUM DIET - STRESSING IMPORTANCE OFADHERENCE MONITOR PATIENTS BLOOD PRESSURE CLOSELY AND NOTIFY MD OF ANY SIGNIFICANT CHANGESINSTRUCT PT TO AVOID OVER-THE-COUNTER COLD AND SINUS MEDS AS THEY CONTAIN VASOCONSTRICTORINST OF HYPERTENSIVE CRISIS MONITOR FOR SS OF ORTHOSTATIC HYPOTENSION
Hypertension
ASSESS PSYCHOLOGICAL STATUS PROVIDE SUPPORTIVE THERAPY PROVIDE REMOTIVATION ASSESSINTERPERSONAL BEHAVIOR ASSIST PATIENT TO DEFINE PROBLEMS amp SOCIAL RELATIONSHIPS GIVE POSITIVEREINFORCEMENT ENCOURAGE PATIENT TO PERFORM PERSONAL HYGIENE amp GROOMING ACTIVITIESASSIST PATIENT TO EXPRESS REALISTIC IDEAS amp PLANS ASSIST PATIENT TO VERBALIZE FEELINGS
Depression
INSTRUCT PATIENT IN CONSEQUENT PHYSICAL L IMITATIONS PLANNING AN ADEQUATE LEVEL OF DAILYACTIVITIES TEACH PT RE ARTHRITIS SS OF EXACERBATION TEACH THE IMPORTANCE OF GOOD POSTUREPREVENT TRAUMA TO JOINTS INST PT IN THE USE OF ASSISTIVE DEVICE AS PRESCRIBED
Osteoarthritis
SKILLED OBSERVATIONEVALUATION ASSESS VITAL SINGS amp SS COMPLICATIONSINSTRUCTEVALUATE UNDERSTANDING OF DISEASE PROCESS DETECTING COMPLICATIONSDIETNUTRITIONAL STATUS SAFETY PRECAUTIONEMERGENCY MEASURES MED-REGIMEN
PSYCH ASSESSMENT ASSESS FOR SS OF EPSDETECT AND ALLEVIATE SOMATIZED COMPLAINTSLIMIT SETTING MOTIVATION TECHNIQUES IMAGERY TECHNIQUES
RELAXATION TECHNIQUESGOAL ORIENTED TASKS
FOLEY INSERTION _______FR FOLEY WITH___________cc BALLONCHANGE Q MONTH amp PRN x3 FOR CLOGGED LEAKING OR ACCIDENTAL REMOVALINST DRESSING CHANGES ________________________ MONITOR FOR SS COMPLICATIONS amp NOTIFY MD
INST SS INFECTION
MONITOR STATUS OF WOUND OR DECUBITUS (place) ______________INST INFECTION CONTROL MEASURES
INST GOOD NUTRITION TO FACILITATE HEALINGMEASURE AND RECORD WOUND or DECUBITUS SIZE AT SOC AND AT LEAST WEEKLY THEREAFTEROPEN WOUND CAREDRESSING CLEANSE WOUND WITH ___________ TO RINSE WITH __________ AND APPLY______________ AND PRN
OBSERVE AND RECORD TYPE AND AMOUNT OF DRAINAGE COLOR INFECTION SWELLING REDNESS PAINDE CUB ITUS CAR EDR ESS ING CLEAN SE W OUN D WITH ___________ TO R IN SE WITH __________ AN D APP LY ______________ AN D PR N
TEACH THE PATIENT HOW TO USE A METERED-DOSE INHALER MAINTAIN EFFECTIVE AIRWAY CLEARANCE
EMPHASIZE THE IMPORTANCE OF ADEQUATE DAILY FLUID INTAKE
PROMOTE AN EFFICIENT BREATHING PATTER
INST INFECTION CONTROL amp PULMONARY HYGIENE INST COMPLICATIONS IN CARDIOPULMONARY STATUSINST PREVENTION OF COMPLICATIONS IE AVOID OVER-EXERTION CHILLING CROWDS ETC
INST D ISEASE PROCESS amp MAINTENANCE
INSTRUCT COUGHING DEEP BREATHING EXERCISES INST PATIENT TO MAINTAIN ADEQUATE REST PATTERN
MANAGEMENT AND EVALUATION OF A PATIENT CARE PLAN TEACHING AND TRAINING DISEASE PROCESS SKIN CARE WOUND CAREDRESSING CHANGE DECUBITUS CARE MEDICATION REGIMEN DIETNUTRITIONHYDRATION COMPLICATIONS OF ENT FEEDING AS INDICATED
PAIN CONTROL MEASURES SYMPTOM CONTROL MEASURES SINGSSYMPTOMS OF INFECTION SAFETYPREVENTION OF INJURY EMERGENCY PLANS OXYGEN ADMINISTRATION
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GOALSREHABILITATION POTENTIAL CMS485 (POC)Included as reference only your Professional Staff must reviewupdatepersonalizeapprove the goals
DISCHARGE PLANNING DISCUSSED WITH PATIENT Yes No REHAB POTENTIAL ExcellentPoor Fair Good
SIGNATUREDATES
X DateStaff Completing the OASIS (signaturetitle)
OASIS INFORMATION
Data Entry Date amp Locked Date SubmittedQA Date Reviewed
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SN - GOALSMRMS _________________ WILL EXHIBIT VITAL SIGNS WITHIN ACCEPTABLE RANGE AND STABILIZED DISEASE PROCESSVERBALIZES KNOWLEDGE OF DISEASE MANAGEMENT MEDICATIONS SIDE EFFECTS PRECAUTIONS DIET FLUIDS TREATMENT PROGRAM SS NECESSITATING MEDICAL ATTENTION EMERGENCY CARE
STABILIZATION OF PSYCHOLOGICAL STATUS WITHIN DISEASE LIMITS TO REDUCE THE PATIENTS ANXIETY LEVELDEPRESIONANXIETY CONTROLED TROUGH MED REGIMEN INTERVENTIONS
ANEMIA CONTROLLED THROUGH MED REGIMEN IMPROVED HEMATOLOGIC STATUS
General
Psychiatric
A n e m i aHEALED WOUND WITHOUT INFECTION OR COMPLICATIONS DEMONSTRATE PROPER WOUND CARE
Wound Care
PTSO SHOULD UNDERSTAND THE NATURE SYMPTOMS STAGE AND PROGRESSION OF ALZHEIMERS DISEASEKNOW HOW TO RECOGNIZE PTS OWN STRESS AND WAYS TO PREVENT OR REDUCE IT PROMOTE SOCIAL INTERACTION AS TOLERATED BY THE PATIENT
Decubitus
DEMONSTRATE STRATEGIES TO BE USED DURING A COUGHING EPISODE HELP THE PATIENT IDENTIFY FACTORSTHAT MAY CAUSE ASTHMA ATTACKS OR CONTRIBUTE TO THEMAsthma
SAFELY ADMINISTERS INJECTION COMPREHEND RATIONALE FOR AND IS ABLE TO ROTATE INJECTION SITESCOMPREHEND SAFETY FACTORS IN SYRINGENEEDLE DISPOSALPATIENTCG ABLE TO MONITOR BLOOD SUGAR CORRECTLY WITHOUT ASSISTANCEABLE TO NOTIFY MD OF ALTEREDOUT OF RANGE RESULTS
InsulinGlucometer
DISCHARGE PT WHEN BLOOD SUGARS ARE WITHIN THE NORMAL FOR PATIENT RANGEKNOW THE ACCEPTABLE RANGE FOR BLOOD SUGAR LEVEL COMPLY WITH DIET RESTRICTIONS Diabetes
MellitusRETURN TO SELF-MANAGEMENT OF HEALED FRACTURED
FractureKNOW ABOUT SIGNS SYMPTOMS AND PRECIPITATING CAUSES OF CHF KNOW HOW TO TAKE THE PULSE AND KNOWTO CONSULT THE DOCTOR BEFORE CONTINUING MEDICATION IF THE PULSE RHYTHM CHANGES KNOW TOA V O I D S M O K I N G A N D S M O K Y E N V I R O N M E N T S A N D P E R S O N S W I T H I N F E C T I O N S E S P E C I A L L Y R E S P I R A T O R Y I N F E C T I O N S
CHF
UNDERSTAND THAT HYPERTENSION IS A CHRONIC DISEASE REQUIRING LIFE LONG TREATMENT EXHIBIT BLOODPRESSURE READINGS CONSISTENTLY WITHIN NORMAL OR SPECIFIED RANGE DEMONSTRATE ADHERENCE TO ALOW-SALT LOW-FAT DIET
Hypertension
HELP THE PATIENT ACHIEVE PAIN RELIEVE AND REDUCE ANGINA EPISODES UNDERSTAND THE CAUSE OFANGINA PECTORIS AND POSSIBLE PRECIPITATING FACTORS FOR AN ATTACK IDENTIFY PERSONAL STRESSORSTHAT MAY CONTRIBUTE TO THE PROBLEM AND BEGIN ELIMINATING OR MINIMIZING THEM KNOW WAYS TOREDUCE THE FREQUENCY OF ANGINA EPISODES
Angina
HEALED DECUBITUS WITHOUT INFECTION OR COMPLICATIONS DEMONSTRATE PROPER DECUBITUS CARE
Alzheimers
UNDERSTAND SS OF BRONCHITIS OR OTHER RESPIRATORY INFECTION AND DISEASE EXACERBATIONUNDERSTAND THE DANGERS OF SMOKING AIR AND CHEMICAL POLLUTANTS AND RESPIRATORY INFECTIONUNDERSTAND AND PRACTICE COUGHING AND DEEP-BREATHING EXERCISES
Respiratory
DAILY COMPLIANCE WCATHETER CARE DECREASE RISK OF URINARY INFECTIONCatheter
INCREASED PAIN RELIEF INCREASED STRENGTH AND ENDURANCE COMPREHEND AND DEMONSTRATE HOME EXERCISEOsteoarthritis
AIDE - GOALS
GAIT PATTERN ENDURANCE STRENGTH AND BALANCE WILL IMPROVE AND PATIENT WILL DEMONSTRATECORRECT BODY MECHANICS WIN 4-6 WKS PTCG WILL COMPREHEND AND DEMONSTRATE HOME EXERCISEPROGRAM WITHIN 4-6 WKS
FAIR-TO BE ABLE TO CARRY OUT MINIMAL ADLS WITH AVAILABLE HOME SUPPORTWILL NOT BE ABLE TO CARRY OUT ADLS WITHOUT MAXIMUM SUPPORT
RETURN TO INDEPENDENT AMBULATION BE SAFE IN SELF CAREPATIENT WILL BE ABLE TO FUNCTION WITH ASSISTANCE OF CAREGIVERWITHIN HESHE CURRENT LIMITATIONS AT HOME
PATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HISHER CURRENT LIMITATIONS AT HOME
PT - GOALS
GOOD RETURN TO PREVIOUS LEVEL OF ADLS INDEPENDENTLY
GAIT PATTERN ENDURANCE STRENGTH AND BALANCE WILL IMPROVE AND PT WILL DEMONSTRATECORRECT BODY MECHANICS WITHIN _____ WEEKS
PATIENT WILL EXPERIENCE A DECREASE IN PAIN
PTCG WILL COMPREHEND AND DEMONSTRATE HOME EXERCISEPROGRAM WITHIN _____ WEEKS
OT PATIENT WILL EXHIBIT IMPROVEMENT IN COPING IN ADLSIADLS MUSCLE USEMOTORCOORDINATIONNEURO RESPONSEUSE OF ORTHOTIC SPLINTING ANDOR EQUIPMENT
OT - GOALS
PATIENT WILL DEMONSTRATE FUNCTIONAL COMMUNICATIONS EXHIBIT MAXIMUM VERBAL AND SENTENCEFORMULATION AND COMPREHENSION WITHIN DISEASE LIMITS WITHIN _____ WEEKS
ST - GOALS
PATIENT WILL DEMONSTRATE APPROPRIATE USE OF FUNCTIONAL VERBALNON-VERBALCOMMUNICATIONS SYSTEMS WITHIN _____ WEEKS
PATIENT WILL DEMONSTRATE IMPROVED READINGWRITING USE OF GESTURESNUMBERS WITHIN _____ WEEKS
PATIENT WILL DEMONSTRATE IMPROVED SWALLOWINGCHEWINGORALMOTOR CONTROL WITHIN _____ WEEKS
PATIENT WILL HAVE ADEQUATE SUPPORT TO REMAIN IN HOME WITH ASSISTANCE OF COMMUNITYRESOURCES FOR FINANCIAL TRANSPORTATION AND PERSONAL CARE ASSISTANCE WITHIN _____ WEEKS
MSW - GOALSPSYCHOSOCIAL EVALUATION WILL BE PERFORMED PTCG WILL BE COUNSELED REGARDING MANAGEMENTamp ADJUSTMENT TO ILLNESS LONG TERM PLANNING AND DECISION MAKING APPROPRIATE COMMUNITYRESOURCE REFERRALS WILL BE MADE
WILL DISCHARGE THE PATIENT WITHIN 60 DAYS WHEN PATIENT ANDORCAREGIVER ISARE ABLE TO DEMONSTRATE KNOWLEDGE OF DISEASE MANAGEMENT SS COMPLICATIONSPATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HISHER CURRENT LIMITATION AT HOME
ABLE TO REMAIN IN HOMERESIDENCEALF WITH ASSISTANCE OF PRIMARY CAEGIVERSUPPORT AT HOMEABLE TO UNDERSTAND MEDICATION REGIMEN AND CARE RELATED TO HISHER DISEASEWILL BE DISCHARGE WHEN MAXIMUM FUNCTIONAL POTENTIAL REACHED
Patient Name Med Record
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XPatient Signature if required optional if itinerary is used
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- PT ID PERFORMED VIA NAME DOB FACE RECOGNITION AND ADDRESS BEFORE SERVICE PROVIDED Off
- TIME IN
- TIME OUT
- Agency Name SALUD HOME CARE INC
- Phone 305-555-5555
- Employees NameTitle Completing the OASIS
- who has signed the plan of care
- Physician name
- Address 1
- Address 2
- Phone Number
- Address 1_2
- Address 2_2
- Patient Phone
- Reason
- Name
- Other Physician if any
- Phone_2
- Address 1_3
- Address 2_3
- Phone Number_2
- REFERRAL SOURCE if not from Primary Physician
- undefined_6
- Phone_3
- Fax
- Evacuation Form needed Emergency Reg 1
- Evacuation Form needed Emergency Reg 2
- EMERGENCY CONTACT
- Address
- Comments 1
- Comments 2
- Phone_4
- Relationship
- OTHER
- Comment 1
- Comment 2
- 11 Other specify
- a
- b
- 7 Other specify
- c
- d
- e
- f
- a_2
- b_2
- d_2
- e_2
- f_2
- a_3
- b_3
- d_3
- Comment if needed 1
- Comment if needed 2
- a_4
- a_5
- a_6
- Date 23
- undefined_7
- undefined_8
- b_4
- b_5
- b_6
- Date_2
- undefined_9
- undefined_10
- Date_3
- undefined_11
- undefined_12
- d_4
- d_5
- d_6
- Date_4
- undefined_13
- undefined_14
- Date_5
- undefined_15
- undefined_16
- Date_6
- undefined_17
- undefined_18
- 12 1
- 12 2
- Date_7
- undefined_19
- undefined_20
- Date_8
- undefined_21
- undefined_22
- MAIN REASON FOR HOME HEALTH CARE 1
- MAIN REASON FOR HOME HEALTH CARE 2
- Fractures site
- Surgeries site
- Cancer site
- Open Wound site
- Decubitus site
- Other specify
- Other
- Pending or Needed
- Yes Number of times
- Reason s Dates
- MobilityAmbulatory devices used
- Other specify_2
- undefined_23
- Comments if needed 1
- Comments if needed 2
- Comments if needed 3
- Comments if needed 4
- undefined_24
- Name_2
- Phone number if different from patient
- Relationshiphealth statusability to help 2
- Any paid help explain
- Specify 1
- Specify 2
- Specify 3
- Any ears surgeryprocedure
- Date_9
- Otherspecify 1
- Otherspecify 2
- Other agencies involved in care 1
- Other agencies involved in care 2
- 1
- 2
- Other_2
- Infections
- Cataract surgery Site
- Date_10
- Other eyes surgery Site
- Date_11
- explain 1
- explain 2
- Any nose surgery
- Date_12
- Other specify_3
- 1_2
- 2_2
- MassesTumors site
- Lesions explain
- Any surgeryprocedure
- Other specify 1
- Other specify 2
- Other specify 3
- Date_13
- Other specify_4
- No Problem
- Medication
- Other_3
- Pain control treatmentmeds Side effect mark
- Other_4
- Is there a regular pattern to the pain explain
- Other_5
- Comment
- What was the outcome
- Type II OnsetExacerbation date
- DietOral control specify
- INSULIN dosage frequency scale explain
- 1_3
- 2_3
- Since
- Other_6
- A1c
- BS
- mgdL DateTime
- Blood sugar ranges
- site 1Location site
- site 2Location site
- site 3Location site
- Frequency
- Other_7
- site 1New Onset Exacerbation
- site 2New Onset Exacerbation
- site 3New Onset Exacerbation
- Able to use Glucometer
- site 1Present level 010
- site 2Present level 010
- site 3Present level 010
- Diabetes Management Problems explain 1
- Diabetes Management Problems explain 2
- Other Endocrine problems
- site 1Occasional y Cont Intermittent Frequency Frequently
- site 2Occasional y Cont Intermittent Frequency Frequently
- site 3Occasional y Cont Intermittent Frequency Frequently
- site 1Pain type ach ng burn ng rad ating neura gia etc
- site 2Pain type ach ng burn ng rad ating neura gia etc
- site 3Pain type ach ng burn ng rad ating neura gia etc
- Anemia specify type if known
- site 1Feeling of pain internal external acute chronic
- site 2Feeling of pain internal external acute chronic
- site 3Feeling of pain internal external acute chronic
- site 1Pain is worse morning
- site 2Pain is worse morning
- site 3Pain is worse morning
- Immunodeficiency problems explain
- Other 1
- Other 2
- Other_8
- explain 1_2
- explain 2_2
- explain 3
- explain 4
- Other specify 1_2
- Other specify 2_2
- undefined_25
- undefined_26
- undefined_27
- undefined_28
- undefined_29
- undefined_30
- undefined_31
- undefined_32
- undefined_33
- undefined_34
- undefined_35
- undefined_36
- M1310 Pressure Ulcer Length Longest length headtotoe
- undefined_37
- cm
- greatest width perpendicular to the length
- M1314 Pressure Ulcer Depth Depth of the same pressure ulcer from
- cm_2
- visible surface to the deepest area
- undefined_38
- cm_3
- 1_4
- 2_4
- 3_2
- Other_9
- 4_2
- Caregiver name
- Other_10
- cant integument findings
- Observation
- Observation_2
- Caregiver name_2
- Other_11
- Wound cleaned with specify
- Wound irrigated with specify
- 1 Size
- cm width
- Wound packed with specify
- Location
- Other_12
- Wound dressingcover applied specify
- 2 Size
- cm width_2
- Comments 1_2
- Comments 2_2
- Location_2
- Other_13
- Sizecm LengthxWidthxDepth
- Sizecm LengthxWidthxDepth_2
- Diagram 4Sizecm LengthxWidthxDepth
- Tunneling Undermining cm
- Tunneling Undermining cm_2
- Diagram 4Tunneling Undermining cm
- Stage IIIIIIIV pressure uIcers only
- Diagram 4Stage IIIIIIIV pressure uIcers only
- Odor Fool normal etc
- Diagram 4Odor Fool normal etc
- Edema pedal sacral p tting etc
- Diagram 4Edema pedal sacral p tting etc
- Appearance of the Wound Bed
- Diagram 4Appearance of the Wound Bed
- Treatment Ordered
- Diagram 4Treatment Ordered
- Other_14
- Other_15
- Other_16
- Other_17
- Yes 1
- Yes 2
- Yes 3
- Height
- Weight
- Radiating to
- GainLoss
- lb X
- Frequencyduration
- Sittinglying R
- L
- Standing R
- L_2
- Medication_2
- Temperature
- Other_18
- Apical
- Brachial
- Radial
- Carotid
- Dependent
- Pitting 1234
- Respirations
- Site
- Cramps site
- Disease Management Problems explain
- Right Upper
- Right
- Right Lower
- 1_5
- 2_6
- 3_3
- Left
- Left Upper
- Left Lower
- Pacemaker Date
- Last date checked
- SOB on minimal effortwalk
- Type
- fy
- Other Prob 1
- Other Prob 2
- O2
- Trach sizetype
- CaregiverfamilyOther
- Yes explain 1
- Yes explain 2
- Other_19
- Comments 1_3
- Comments 2_3
- Increase fluids
- Restrict fluids
- Frequency_2
- Amount
- Yes describe 1
- Yes describe 2
- Frequency_3
- Other 1_2
- Other 2_2
- Nocturia x
- Bowel Off
- undefined_52
- Diapersother
- Other_20
- No
- 2TOTAL
- Urinary Catheter Type
- Last changed on
- Foley inserted date
- with
- Inflated balloon with
- Irrigation solution Type specify
- Amount_2
- mL Frequency
- Returns
- No_2
- 1_6
- 2_7
- Describe at risk intervention and plan 1
- Describe at risk intervention and plan 2
- Describe at risk intervention and plan 3
- DischargeDrainage describe
- Lesions
- Blisters
- Masses
- Cysts
- Wart
- Other specify_5
- Surgical alteration
- Prostate problem BPH TURP Date
- undefined_53
- undefined_54
- Selftesticular exam Frequency
- Hysterectomy Date
- undefined_55
- undefined_56
- Date last PAP
- undefined_57
- undefined_58
- Results
- Breast selfexam frequency
- Mastectomy R L Date
- undefined_59
- undefined_60
- Other specify_6
- Last BM
- Diarrhea Frequency
- Bowel regimeprogram
- Incontinence Off
- Urinary Off
- Diapersother_2
- Other_21
- te describe skin around stoma
- Ileostomycolostomy s 2
- Ileostomycolostomy s 3
- Ileostomycolostomy s 4
- Ileostomycolostomy s 5
- Headache Location
- Frequency_4
- Other_22
- Migraine Frequency
- Site_2
- Weakness UE LE Location
- Other specify_7
- Site_3
- IV
- Pump typespecify
- Hand grips Equal Unequal specify
- Feedings Type amtrate
- Strong Weak specify
- Psychotropic drug use specify
- Flush Protocol amtspecify
- DoseFrequency
- Other_23
- Other specify 1_3
- Other specify 2_3
- DressingSite care specify 1
- DressingSite care specify 2
- Interventions instructionsComments 1
- Interventions instructionsComments 2
- Following Un
- versalStandard precautions
- NA
- No Problem_2
- Pain Frequency
- Abdominal girth
- Bowel sounds active absent hypo hyperactive x
- 3 Forgetful Off
- 4 Depressed Off
- 6 Lethargic Off
- 5 Disoriented Off
- 7 Agitated Off
- 2 Comatose
- 8 Other Off
- Forgetful at times Off
- Irritable Off
- Anxious Off
- Alert Off
- Describe 1
- Describe 2
- undefined_61
- Needs interpreter
- Comments 1_4
- Comments 2_4
- Higher Educational Level
- Fracture location
- Swollen painful joints specify
- Explain
- Contractures Joint
- Spiritual resource
- Location_3
- Phone No
- Atrophy
- Other_27
- Explain 1
- Explain 2
- Decreased ROM
- Paresthesia
- Weakness
- Other_28
- Inappropriate followthrough in past
- Amputation BKAKUE RL specify 1
- Amputation BKAKUE RL specify 3
- Amputation BKAKUE RL specify 4
- Treatment
- Treatment_2
- Other specify 1_4
- Other specify 2_4
- History of Falls past 3 months 12 falls M1032
- V s on Status Poor w or w o glasses M1200
- Vision Status Poor Legally blind M1200
- Gait and Balance Balance problem while standing
- Gait and Ba ance Balance problem while walking
- Gait and Balance Decreased muscular coordination
- Pred spos ng D seases 12 present
- Predisposing D seases 3 or more present
- Equipment Issues Oxygen tubing
- 1Row1
- PlanComments 1
- PlanComments 2
- Comment_2
- undefined_62
- b Ambulation
- c Transfer
- DOther specify
- 7Independent in home 1
- 7Independent in home 2
- Other 1_3
- Other 2_3
- Typebrand
- Size
- Gauge
- Length
- Insertion site
- Insertion date
- Flush solution
- Frequency_5
- Injection cap change frequency
- Dressing change frequency
- Other_29
- Siteskin condition
- External catheter length
- OtherComment
- fluid overload Other
- Circumference of arm
- Huber gaugelength
- Yes date
- Last flushed date
- Siteskin condition_2
- Infusion solution typevolumerate
- Dressing
- OtherComment 1
- OtherComment 2
- Drug Name
- Dose
- Route
- Frequency_6
- Duration of therapy
- Drug Name_2
- Dose_2
- Route_2
- Frequency_7
- Duration of therapy_2
- CommentPlan 1
- CommentPlan 2
- Pump type specify
- Other_30
- Lab draws
- Infusion care provided during visit 1
- Infusion care provided during visit 2
- Infusion care provided during visit 3
- Antibiotic therapy
- 1_7
- 2_8
- Other_31
- Removing line date if know
- BraceOrthotics specify 1
- BraceOrthotics specify 2
- BraceOrthotics specify 3
- Needs specify 1
- Needs specify 2
- Oxygen HME Co
- Prosthesis RUE RLE LUELLEOther
- HME Rep
- Grab bars BathroomOther
- Hospital bed Semielec Crank Spec
- Other_32
- NA_2
- Phone_5
- n care
- PlanComments
- N
- Other_33
- undefined_63
- Physical Therapy Total visits
- Speech Therapy Total visits
- visits
- Other Therapy Total visits
- Patient is not assessed to be at risk for falls
- No pain identified
- Patient has no pressure ulcers with need for moist wound healing
- O
- Noncompliance with drug orders
- Expected Outcome
- Patient unable to perform own Wound Care due
- Pat
- to
- Abd Pads Off
- Underpads size
- undefined_68
- Special mattress overlay
- Angiocatheter size
- Ostomy pouch brand size
- Pressure relieving device
- Ostomy wafer brand size
- undefined_69
- SYRINGES
- Batteries size
- Skin protectant
- Glucometer
- Hydrocolloids
- undefined_70
- FOLEYCATH SUPPLIES
- Syringes size
- size
- Oxygen concentrator
- Feeding tube
- Ointment
- Acetic acid
- Other 1_4
- Other 2_4
- Other 3
- Tens unit
- KLING 4
- Other 1_5
- Other 2_5
- Other 3_2
- PatientCG educationteaching this visit for
- MEDICATION Off
- DISEASE PROCESS COMPLICATIONS Off
- undefined_71
- SS OF Off
- ILEAL CONDUITOSTOMY Off
- DIET FLUIDS Off
- undefined_72
- undefined_73
- SKINFOOT CARE Off
- INFECTION CONTROL Off
- OTHER INSTRUCTIONS GIVEN
- Caregiver present during the visit
- NEEDS FURTHER TEACHING Off
- No_3
- Skilled Observation Assessment
- ent Educat
- Wound Care Dress
- Diabetic Observation Care
- Correct handwashing technique followed SG 1
- Correct handwashing technique followed SG 2
- Correct handwashing technique followed SG 3
- Correct handwashing technique followed SG 4
- 21 Included as reference only your Professional Staff must reviewupdatepersonalizedapprove the orders
- SN ORDERS FREQUENCYDURATION
- S COMPLICATIONS
- TH GLUCOMETER OR
- ON
- TEACH GLUCOMETER OR
- NSERTION
- TH
- INST DRESSING CHANGES
- MONITOR STATUS OF WOUND OR DECUBITUS place
- ADMINISTER PRESCRIBED INJECTABLE
- USING
- TH_2
- TH_3
- AND APPLY
- CLEANSE WOUND WITH
- NSE WITH
- AND APPLY_2
- OTHER_2
- DE ORDERS FREQUENCYDURATION
- PT ORDERS FREQUENCYDURATION
- OT ORDERS FREQUENCYDURATION
- ST ORDERS FREQUENCYDURATION
- MSW ORDERS FREQUENCYDURATION
- Included as reference only your Professional Staff must reviewupdatepersonalizeapprove the goals 22
- MRMS
- PROGRAM WITHIN
- CORRECT BODY MECHANICS WITHIN
- COMMUNICATIONS SYSTEMS WITHIN
- undefined_75
- undefined_76
- Date_14
- QA Date Reviewed
- undefined_77
- undefined_78
- Data Entry Date Locked
- undefined_79
- undefined_80
- Date Submitted
- undefined_81
- undefined_82
- SOCD
- SOCM
- SOCY
- SOCM1
- SOCD1
- SOCY1
- Check Box2 Off
- Check Box3 Off
- Check Box4 Off
- TOM
- TOD
- TOY
- FDM
- FDD
- FDY
- Prov 1071523
- BrID
- Check Box9 Yes
- BrIDno
- Check Box11 Off
- DLCM
- DLCD
- DLCY
- LVM
- LVD
- LVY
- DNR1 Off
- Check Box19 Off
- STFL
- PZC
- MCN
- NOMC Off
- SSN1
- SSN2
- SSN3
- SSUK Off
- MAN
- MAUK Off
- DOBM
- DOBD
- DOBY
- SEX Off
- MR
- First
- MI
- Last
- Suffix
- RACE2 Off
- RACE3 Off
- RACE4 Off
- RACE5 Off
- RACE1 Off
- RACE6 Off
- PS3 Off
- PS0 Off
- PS1 Off
- PS4 Off
- PS5 Off
- PS6 Off
- PS7 Off
- PS8 Off
- PS9 Off
- PS10 Off
- PS11 Off
- PS2 Off
- PSUK Off
- Ecode
- COMP Off
- DACM
- DACD
- DACY
- REA Off
- DM
- DD
- DY
- RDM
- RDD
- RDY
- REFDM
- REFDD
- REFDY
- EPT Off
- 14D2 Off
- 14D3 Off
- 14D4 Off
- 14D5 Off
- 14D6 Off
- 14D7 Off
- 14D8 Off
- Check Box39 Off
- icd9c
- icd9a
- icd9b
- icd9d
- icd9e
- icd9f
- Check Box5 Off
- Check Box7 Off
- icd9b2
- icd9c2
- icd9d2
- C_2
- icd9e2
- icd9f2
- icd9a2
- icd9b3
- icd9c3
- C_3
- icd9a3
- icd9d3
- 1005d
- 1005m
- 1005y
- 1018-2 Off
- 1018-1 Off
- 1018-4 Off
- 1018-5 Off
- 1018-6 Off
- 1018-7 Off
- 1018-NA Off
- 1018-UK Off
- 1018-3 Off
- 1012-na Off
- 1012-uk Off
- Radio Button11 Off
- v1020b
- C_5
- e_5
- f_5
- C_6
- e_6
- f_6
- c_4
- e_4
- f_4
- v1020c
- v1020d
- v1020e
- v1020f
- v1020a
- e1020b
- e1020c
- e1020d
- e1020e
- e1020f
- e1020a
- ev1020b
- ev1020c
- ev1020d
- ev1020e
- ev1020f
- ev1020a
- sp12-1
- sp12-2
- Radio Button12 Off
- Radio Button13 Off
- rad0 Off
- rae0 Off
- rdf0 Off
- phhp Off
- phrp1 Off
- phot1 Off
- phoa1 Off
- phfc1 Off
- phca1 Off
- phin1 Off
- phga1 Off
- phif1 Off
- phsg1 Off
- phwd1 Off
- phdc1 Off
- phgn1 Off
- rddmi Off
- imin Off
- inh1n1 Off
- fwpn Off
- fwtn Off
- fwot Off
- phdm1 Off
- PHNY Off
- phcd1 Off
- 10304 Off
- 10301 Off
- 10302 Off
- 10303 Off
- 10327 Off
- M1034 Off
- HBR1 Off
- HBR2 Off
- HBR3 Off
- HBR4 Off
- HBR5 Off
- HBR6 Off
- HBR7 Off
- HBR8 Off
- HBR9 Off
- HBR11 Off
- HBR12 Off
- HBR10 Off
- HBR13 Off
- SOBFT
- 10321 Off
- 10322 Off
- 10333 Off
- 10324 Off
- 10325 Off
- 10336 Off
- M11001 Off
- M1100b Off
- M1100c Off
- Relationshiphealth statusability to help 1
- 10361 Off
- 10362 Off
- 10363 Off
- 10364 Off
- 10365 Off
- 10366 Off
- 1210d Off
- 1210an Off
- 1210hea Off
- 1210OTH Off
- 1210TIN Off
- 1210NP Off
- 12102 Off
- 12101 Off
- 1210uk Off
- 1210h Off
- 1210v Off
- 1200CAT Off
- 1200OTH Off
- 1200JA Off
- 1200CATRL Off
- 1200OTHER Off
- 1200PT Off
- 1200GLAU Off
- 1200NOP Off
- NOSECON Off
- NOSEEP Off
- NOSELS Off
- NOSESINP Off
- NOSEASG Off
- NOSEOTHSP Off
- NOSENP Off
- THROATDY Off
- TROATL Off
- THROATOTH Off
- 1200BV Off
- 1200LB Off
- THROATHO Off
- THOATSO Off
- THROATNP Off
- 1200GL Off
- 1200CO Off
- 1200PR Off
- 1200IN Off
- M1200 Off
- M1220 Off
- M1230 Off
- MOUTHMas Off
- MOUTHGI Off
- MOUTHULC Off
- MOUTHTOO Off
- MOUTHANY Off
- MOUTHOTH Off
- MOUTHNP Off
- M1240 Off
- M1242 Off
- MOUTHDE Off
- MOUTHUP Off
- MOUTHLO Off
- MOUTHPAR Off
- COPYN Off
- MKMEDP Off
- CPCYN Off
- DPRYN Off
- ICPYN Off
- TURGGP Off
- BESTPAINSC2
- WORSES2
- BESTPAINSC
- WORSESC
- BESTPAINSC3
- WORSESC3
- FACESOBS Off
- SCALE010 Off
- WPSL Off
- WPMA Off
- WPMV Off
- WPAMB Off
- WPIMM Off
- WPTR Off
- WPOTH Off
- WPNP Off
- NVIM Off
- WRP4 Off
- WRP5 Off
- WRP6 Off
- WRP7 Off
- WRP8 Off
- WRP9 Off
- WRPOTH Off
- TKMEDNV Off
- TKMEDLDD Off
- TKMEDD Off
- TKMED23 Off
- TKMEDLT3 Off
- PCTSL Off
- PTXSEN Off
- PTXSEV Off
- PTXSECF Off
- PRDOCC Off
- PTXSEOTH Off
- PRDCONT Off
- WRP1 Off
- WRP2 Off
- WRP3 Off
- PRDINT Off
- PRDFRQ Off
- PHYNOTPT Off
- PHYNOTSTF Off
- NVIG Off
- NVIC Off
- NVIAF Off
- DMIJUV Off
- DMTPII Off
- INSDGFQ Off
- DMODIET Off
- ADMOTH Off
- symphyg Off
- sympfat Off
- symhypog Off
- endopcgr Off
- endopostpra Off
- endorand Off
- endolab Off
- bsrange Off
- bsranptcg Off
- endomonsf Off
- endomoncg Off
- endomonsn Off
- endomonoth Off
- dmNapb Off
- othendopb Off
- enlthyr Off
- intoheatcol Off
- endonp Off
- HEMAANE Off
- HEMABLEED Off
- HEMAHEMO Off
- HEMAINMO Off
- HEMAOTH Off
- HEMANP Off
- SKINITCH Off
- SKINRASH Off
- SKINDRY Off
- SKINSCL Off
- SKINRED Off
- SKINBRU Off
- SKINECCH Off
- SKINPALL Off
- SKINJAU Off
- ADMSELF Off
- ADMSCGF Off
- ADMNURS Off
- SKINNP Off
- m1300 Off
- M1302 Off
- M1306 Off
- M1320 Off
- M1322 Off
- M1324 Off
- M1330 Off
- M1332 Off
- M1334 Off
- M1340 Off
- M1342 Off
- M1350 Off
- WCPYN Off
- IPDMYN Off
- APHYN Off
- SDRBY Off
- SDRSN Off
- SDRCG Off
- SDRPT Off
- SDROTH Off
- TECST Off
- TECCL Off
- WDCLW Off
- WDIRRW Off
- WDPKW Off
- WDDREW Off
- DBFEXD Off
- DBFEX2D Off
- DBFEXEOD Off
- DFEX2WK Off
- DBNFEXWK Off
- DFEXOTH Off
- PDPPRL Off
- PDPARL Off
- LSWRL Off
- endobm Off
- endotv Off
- fbs Off
- LSCDRL Off
- ASCCFR Off
- ASCCFL Off
- Right for
- ASCCFLF
- TRINR Off
- BURRL Off
- LEGHP Off
- LEGHAB Off
- DBFEXRN Off
- DFEXCG Off
- DBFEXPT Off
- DBFEXOT Off
- EXSER Off
- EXSERG Off
- EXSANG Off
- EXSER2 Off
- EXSERG2 Off
- EXSANG2 Off
- SHOV Off
- SHAPRD Off
- SHAPOTH Off
- SHOV2 Off
- SHAPRD2 Off
- SHAPOTH2 Off
- cm length
- cm length2
- DBFTEXRNPT Off
- EXDYN Off
- EXDYN2 Off
- APHYN2 Off
- APHYN3 Off
- Loc3w
- Loc2w
- Loc1w
- Loc4w
- Typew1
- Typew2
- Typew3
- Typw4
- sizw3
- tunnw3
- surrw1
- stomaw1
- surrw1a
- stomaw1a
- surrw3
- surrw3a
- stomaw3
- stomaw3a
- surrw2
- surrw2a
- stomaw2
- stomaw2a
- surrw4
- surrw4a
- stomaw4
- stomaw4a
- statgew2
- statgew3
- Odorw2
- Odorw3
- Edemaw2
- Edemaw3
- appw2
- appw3
- Treatment Ordered_2
- Treatment Ordered_3
- Group10 Off
- draick2 Off
- driack3 Off
- draick4 Off
- colw11 Off
- colw12 Off
- colw31 Off
- colw32 Off
- colw33 Off
- colw34 Off
- colw21 Off
- colw22 Off
- colw23 Off
- colw24 Off
- colw43 Off
- colw44 Off
- ital1u1 Off
- ital1u2 Off
- fsrrepo Off
- frsact Off
- rwgchpt Off
- rwgchcgf Off
- rwgchnur Off
- pulreg1 Off
- pulirreg1 Off
- fsrrespreg Off
- colw41 Off
- colw42 Off
- bpsitly Off
- bpstand Off
- fsrwgrep Off
- fsrwgact Off
- tempaxil Off
- temptymp Off
- pulseappical Off
- pulseradial Off
- pulsebrach Off
- pulsecarot Off
- pulserest Off
- pulsecheyn Off
- pulseactiv Off
- respirirreg Off
- respideath Off
- respaccess Off
- respiapnea Off
- bsckrack Off
- temporal Off
- temprect Off
- chestprad Off
- colw13 Off
- colw14 Off
- consth2 Off
- consthic2 Off
- consth3 Off
- consthic3 Off
- consth4 Off
- consthic4 Off
- chestpyes Off
- chestpainno Off
- consth1 Off
- consthic1 Off
- cpsubstern Off
- cpviselike Off
- dm5lin
- assocwithsoboe Off
- associawactv Off
- associwsweat Off
- cphowreloth Off
- cphowrelrest Off
- cphowrelmeds Off
- cppalarr Off
- cppalpfast Off
- cppalpslow Off
- cppalpfatig Off
- cpedema Off
- cpedemapedal Off
- cpangina Off
- cppostural Off
- cplocalized Off
- cpedempedrig Off
- cpedemapedallef Off
- cpedemasacral Off
- cpedemadepend Off
- cpedemapitt Off
- cpedemanonpitt Off
- cstcramp Off
- cardstclaud Off
- cardstcapref Off
- cstcaprefless Off
- castcaprefgreat Off
- csthsreg Off
- csthsirreg Off
- csthsmurmur Off
- cstpacemak Off
- cpstabreassouclear Off
- breassodwheez Off
- bresddimm Off
- chestpaidull Off
- cpache Off
- cpsharp Off
- brsdabset Off
- brsdsobsoboe Off
- brsdsobonmineff Off
- 14001 Off
- 14003 Off
- 14004 Off
- 1400tva Off
- 14002 Off
- 1400car Off
- 14101 Off
- 14102 Off
- 14103 Off
- 14104 Off
- uroops Off
- uropat Off
- urocare Off
- 14000 Off
- urosn Off
- Radio Button2 Off
- 16100 Off
- 16101 Off
- 1400pat Off
- 16concar Off
- 162gm Off
- 16nas Off
- 16npo Off
- 16102 Off
- 161800cal Off
- 16lowfat Off
- 16lowcho Off
- 16incflu Off
- 16restflu Off
- 16exc Off
- 16good Off
- 16fair Off
- 16poor Off
- 16anore Off
- 16nau Off
- 16vom Off
- 16heabur Off
- O2satur
- O2firesaf Off
- O2sn Off
- O2carefamother Off
- O2cough Off
- O2no Off
- O2yes Off
- O2nonprod Off
- O2noc Off
- O2yesc Off
- O2dys Off
- O2rest Off
- O2dADL Off
- O2sliplo Off
- O2nop Off
- O2yesp Off
- 16other Off
- genibur Off
- genihes Off
- genihema Off
- geniolig Off
- geniurg Off
- geninoc Off
- geniincon Off
- geniuri Off
- genidiap Off
- 16lowna Off
- genicyell Off
- genicamber Off
- genicbr0 Off
- genicbt Off
- genicother Off
- genicla Off
- geniclo Off
- genised Off
- geniodno Off
- genifol Off
- geniwitdif Off
- genisup Off
- geniyes Off
- genino Off
- 1620 Off
- 1615 Off
- 1630 Off
- 1630cosn Off
- 1630lBM Off
- 1630diar Off
- 1630rect Off
- 1630hemo Off
- 1630incon Off
- 1630diap Off
- 1630lax Off
- 1630w Off
- 1630d Off
- 1630m Off
- 1630lleost Off
- 1630pat Off
- 1630car Off
- 1630sn Off
- 1630ot Off
- 1630np Off
- 1630follow Off
- genblis Off
- genmass Off
- gencys Off
- genwart Off
- geninf Off
- gensurg Off
- genprost Off
- gensef Off
- genmeno Off
- genhyst Off
- gendisc Off
- geniodyes Off
- gennp Off
- 1630flat Off
- 17001 Off
- 17002 Off
- 17004 Off
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- 1700up Off
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- 1700rec Off
- 1700exp Off
- 1700mot Off
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- 1700fine Off
- 1700gross Off
- 1700paral Off
- 1700stu Off
- 1700halluc Off
- 1700psy Off
- 1700oth Off
- 1700np Off
- EFAD TPN Off
- 17003 Off
- EFAD jej Off
- EFAD iv Off
- EFAD pum Off
- EFDA bol Off
- EFDA con Off
- EFA pat Off
- EFDA sn Off
- EFDA car Off
- EFDAoth Off
- EFDAfu Off
- EFDA na Off
- EFDA np Off
- abd pa Off
- ABD dis Off
- ABD hard Off
- ABD soft Off
- ABD asc Off
- ABD ab Off
- ABD oth Off
- ABD bow Off
- ABD other Off
- ABD ten Off
- EFAD Nas Off
- efad gas Off
- EFAD ot Off
- 17101 Off
- 17102 Off
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- 17104 Off
- 17105 Off
- 17100 Off
- 1720 Off
- gen dis Off
- genbre Off
- genmast Off
- genoth Off
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- 1700mig Off
- genles Off
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- pslb Off
- psni Off
- psd Off
- psnas Off
- lbm Off
- lbps Off
- lbph Off
- lbf Off
- lbs Off
- urw Off
- sceri Off
- 17403 Off
- ps Off
- ABD pn Off
- pslm Off
- psdp Off
- pspl Off
- psrf Off
- psnh Off
- psue Off
- psir Off
- pse Off
- psep Off
- psea Off
- psvep Off
- psin Off
- psph Off
- psab Off
- psfin Off
- msor Off
- msfr Off
- msre Off
- msp Off
- mssw Off
- mscon Off
- msat Off
- msad Off
- mscan Off
- msuns Off
- mstp Off
- mswal Off
- msdec Off
- par Off
- msot Off
- mssh Off
- mswe Off
- mswea Off
- mskp Off
- msother Off
- mshe Off
- mspa Off
- msqua Off
- msoth Off
- msnop Off
- psina Off
- pssi Off
- psnap Off
- psinap Off
- psan Off
- psfat Off
- pswit Off
- psdif Off
- psdis Off
- psdep Off
- psanx Off
- psnp Off
- psade Off
- psdisc Off
- mscom Off
- msamp Off
- FL2 Off
- FL3 Off
- FL7 Off
- FL8 Off
- FL9 Off
- FLA-d Off
- FLb Off
- FLg Off
- FLart Off
- FLdiz Off
- FLhead Off
- FLins Off
- FLanx Off
- FLsob Off
- FLpoor Off
- FLprod Off
- FLheart Off
- FLp Off
- FLu Off
- FLv Off
- FLed Off
- FLc Off
- FLf Off
- FL1l Off
- FL1b Off
- FL1d Off
- FL1p Off
- FL1li Off
- FL1lr Off
- FL1lc Off
- FL1f Off
- FL1n Off
- FL4 Off
- FL6 Off
- FL5 Off
- adl o Off
- adl 1 Off
- adl 2 Off
- adl 3 Off
- 1810 0 Off
- 1810 1 Off
- 18102 Off
- 18103 Off
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- FL1 Off
- 1910sg Off
- 1910sgp Off
- 1910sgd Off
- 1111910sgp Off
- 1910sgo Off
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- 1910sgpat Off
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- 1890na Off
- adlr Off
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- adlm Off
- adlp Off
- adlot Off
- adlst Off
- 18303 Off
- adlcom Off
- 1845 Off
- 1880 Off
- adl Off
- 1850 Off
- 1860 Off
- 1870 Off
- 1900a Off
- 1900b Off
- 1900d Off
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- 18900 Off
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- 1910aw Off
- 1910bw Off
- 1910cnr Off
- 1910do Off
- alleasp Off
- alleggs Off
- alleib Off
- allesulf Off
- allead Off
- alledm Off
- allelod Off
- allepol Off
- alledust Off
- alleother Off
- 20000 Off
- 2000na Off
- 14D1 Off
- 20001 Off
- 20002 Off
- 2010 Off
- 2002 Off
- 2040a Off
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- 2020 Off
- 2030 Off
- infpat Off
- picccir Off
- ivadacc Off
- int Off
- fo Off
- fa Off
- ule Off
- infiv Off
- perip Off
- mc Off
- gros Off
- tun Off
- nt Off
- ld Off
- lt Off
- cl Off
- pat Off
- rn Off
- cg Off
- ivocc Off
- ivflu Off
- res Off
- red Off
- allerno Off
- iv-i Off
- adp Off
- adc Off
- adrn Off
- adoth Off
- pia Off
- athe Off
- eiv Off
- biood Off
- mva Off
- pn Off
- infna Off
- infcare Off
- rldna Off
- 2100a Off
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- pump Off
- smcou Off
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- smal Off
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- smsa Off
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- smsd Off
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- smgup Off
- smst Off
- smcc Off
- smpes Off
- smep Off
- smms Off
- smcp Off
- smcpat Off
- smcht Off
- smcfsh Off
- smpsbp Off
- smoth Off
- oxgava Off
- oxknosw Off
- prr Off
- shan Off
- adi Off
- epci Off
- apn Off
- cih Off
- pmi Off
- sphic Off
- acihsf Off
- dcdmi Off
- dnr Off
- sac Off
- opnc Off
- msr Off
- hsg Off
- asii Off
- gp Off
- fpp Off
- other Off
- pttv Off
- ottv Off
- sttv Off
- ottvist Off
- oxu Off
- oxupe Off
- oufsp Off
- sh Off
- ih Off
- hd Off
- fab Off
- ug Off
- ir Off
- us Off
- nta Off
- pp Off
- mss Off
- ep Off
- ev Off
- sb Off
- adce Off
- sf Off
- ppf Off
- rma Off
- hsd Off
- ppnf Off
- dfc Off
- fpi Off
- dim Off
- imm Off
- ipp Off
- put Off
- cp Off
- ph Off
- sn Off
- ot Off
- st Off
- aid Off
- oth Off
- mfc Off
- nch Off
- oo Off
- mmc Off
- idt Off
- sse Off
- sdi Off
- ncwdo Off
- ddt Off
- eo Off
- no so-cg Off
- nancg Off
- salin Off
- 2x2 Off
- 4x4 Off
- abd Off
- telf Off
- tap Off
- wg Off
- glov Off
- ns Off
- hyd Off
- ks Off
- td Off
- oint Off
- cs Off
- ther Off
- rb Off
- ic Off
- ivsk Off
- ivp Off
- ivt Off
- as Off
- asi Off
- per Off
- et Off
- cid Off
- ip Off
- ss Off
- duo Off
- bs Off
- abs Off
- m2x11 Off
- mt2 Off
- s4x4 Off
- ng Off
- und Off
- ec Off
- ub Off
- op Off
- ow Off
- sat Off
- fol Off
- ls Off
- sc Off
- tc Off
- aa Off
- otth Off
- app Off
- chem Off
- cta Off
- dcfg Off
- hyt Off
- it Off
- syr Off
- glu Off
- es Off
- ft Off
- srk Off
- strk Off
- sstri Off
- is Off
- stst Off
- ta Off
- vg Off
- kl Off
- sr Off
- bath Off
- can Off
- com Off
- smo Off
- prd Off
- egg Off
- hb Off
- hl Off
- efp Off
- neb Off
- oc Off
- pup Off
- pui Off
- or Off
- inj Off
- ivinf Off
- inh Off
- pcbp Off
- fcc Off
- pe Off
- wcd Off
- pai Off
- doc Off
- soa Off
- injr Off
- pt Off
- sup Off
- atu Off
- qc Off
- sd Off
- cht Off
- mep Off
- ncfa Off
- dpd Off
- wdc Off
- dmc Off
- iad Off
- gc Off
- nmd Off
- trc Off
- oca Off
- fc Off
- pfv Off
- oup Off
- uhm Off
- pmh Off
- eim Off
- e911 Off
- puitc Off
- cpdv Off
- dpdp Off
- rp Off
- ko Off
- ipai Off
- iop Off
- iudp Off
- dc Off
- ds Off
- spe Off
- sfcp Off
- ispm Off
- npp Off
- fi Off
- issi Off
- cqm Off
- idc Off
- msw Off
- iicm Off
- ign Off
- ret Off
- mrw Off
- pcd Off
- dccw Off
- ort Off
- epum Off
- meac Off
- pebp Off
- iap Off
- iiph Off
- iccs Off
- ipc Off
- icdb Off
- ipm Off
- ipap Off
- eiad Off
- ipaot Off
- odit Off
- mepc Off
- ttdp Off
- scwc Off
- mr Off
- dn Off
- cef Off
- pcm Off
- si Off
- spi Off
- eplan Off
- oa Off
- nmbs Off
- tg Off
- idp Off
- ipd Off
- icid Off
- igp Off
- ief Off
- ida Off
- nss Off
- api Off
- aps Off
- pst Off
- sib Off
- sdp Off
- ippph Off
- aperi Off
- pf Off
- ap Off
- apv Off
- pa Off
- ans Off
- imb Off
- imt Off
- ewl Off
- acb Off
- mlc Off
- eob Off
- afs Off
- paa Off
- rt Off
- das Off
- got Off
- lsm Off
- dpc Off
- ils Off
- mpb Off
- iao Off
- ihc Off
- mfs Off
- ipcp Off
- tae Off
- iua Off
- tsb Off
- pc Off
- hc Off
- sp Off
- mdc Off
- oh Off
- tpr Off
- ad Off
- awa Off
- psm Off
- gs Off
- wc Off
- lhk Off
- awpc Off
- errand Off
- nlb Off
- fnc Off
- pric Off
- rsf Off
- src Off
- ebc Off
- ppt Off
- gtwa Off
- ebp Off
- eem Off
- nme Off
- nsf Off
- bmt Off
- thm Off
- tt Off
- ism Off
- ephs Off
- irle Off
- isc Off
- atp Off
- mre Off
- te Off
- pas Off
- sfe Off
- pom Off
- sad Off
- isp Off
- fsm Off
- idy Off
- vdt Off
- ar Off
- noc Off
- ldt Off
- mfa Off
- crm Off
- crp Off
- lrp Off
- mrms Off
- sps Off
- acmr Off
- hwi Off
- hdic Off
- psn Off
- dsdc Off
- usb Off
- dcw Off
- saic Off
- dptw Off
- rsm Off
- kss Off
- uhc Off
- hpa Off
- ipi Off
- grp Off
- ftcm Off
- wac Off
- ria Off
- paf Off
- pafi Off
- pwe Off
- ptc Off
- ges Off
- otp Off
- pwdf Off
- pdaf Off
- pdi Off
- pdis Off
- phas Off
- pep Off
- 12100 Off
- allepen Off
- Patient is not diabetic or is bilateral amputee
- mswref Off
- genitonoprob Off
- Urostomy describe skin around stoma Off
- nutrinoprob Off
- O2prod Off
- woraft Off
- woreve Off
- wormor Off
- worsleep Off
- prodsputcol
- fname Off
- Rehabdc1 Off
- mswgwk1
- stgwk2
- stgwk1
- stgwk3
- rhpoor Off
- Clear Form
- E-mail Form
GOALSREHABILITATION POTENTIAL CMS485 (POC)Included as reference only your Professional Staff must reviewupdatepersonalizeapprove the goals
DISCHARGE PLANNING DISCUSSED WITH PATIENT Yes No REHAB POTENTIAL ExcellentPoor Fair Good
SIGNATUREDATES
X DateStaff Completing the OASIS (signaturetitle)
OASIS INFORMATION
Data Entry Date amp Locked Date SubmittedQA Date Reviewed
Page 20 of 20
22
SN - GOALSMRMS _________________ WILL EXHIBIT VITAL SIGNS WITHIN ACCEPTABLE RANGE AND STABILIZED DISEASE PROCESSVERBALIZES KNOWLEDGE OF DISEASE MANAGEMENT MEDICATIONS SIDE EFFECTS PRECAUTIONS DIET FLUIDS TREATMENT PROGRAM SS NECESSITATING MEDICAL ATTENTION EMERGENCY CARE
STABILIZATION OF PSYCHOLOGICAL STATUS WITHIN DISEASE LIMITS TO REDUCE THE PATIENTS ANXIETY LEVELDEPRESIONANXIETY CONTROLED TROUGH MED REGIMEN INTERVENTIONS
ANEMIA CONTROLLED THROUGH MED REGIMEN IMPROVED HEMATOLOGIC STATUS
General
Psychiatric
A n e m i aHEALED WOUND WITHOUT INFECTION OR COMPLICATIONS DEMONSTRATE PROPER WOUND CARE
Wound Care
PTSO SHOULD UNDERSTAND THE NATURE SYMPTOMS STAGE AND PROGRESSION OF ALZHEIMERS DISEASEKNOW HOW TO RECOGNIZE PTS OWN STRESS AND WAYS TO PREVENT OR REDUCE IT PROMOTE SOCIAL INTERACTION AS TOLERATED BY THE PATIENT
Decubitus
DEMONSTRATE STRATEGIES TO BE USED DURING A COUGHING EPISODE HELP THE PATIENT IDENTIFY FACTORSTHAT MAY CAUSE ASTHMA ATTACKS OR CONTRIBUTE TO THEMAsthma
SAFELY ADMINISTERS INJECTION COMPREHEND RATIONALE FOR AND IS ABLE TO ROTATE INJECTION SITESCOMPREHEND SAFETY FACTORS IN SYRINGENEEDLE DISPOSALPATIENTCG ABLE TO MONITOR BLOOD SUGAR CORRECTLY WITHOUT ASSISTANCEABLE TO NOTIFY MD OF ALTEREDOUT OF RANGE RESULTS
InsulinGlucometer
DISCHARGE PT WHEN BLOOD SUGARS ARE WITHIN THE NORMAL FOR PATIENT RANGEKNOW THE ACCEPTABLE RANGE FOR BLOOD SUGAR LEVEL COMPLY WITH DIET RESTRICTIONS Diabetes
MellitusRETURN TO SELF-MANAGEMENT OF HEALED FRACTURED
FractureKNOW ABOUT SIGNS SYMPTOMS AND PRECIPITATING CAUSES OF CHF KNOW HOW TO TAKE THE PULSE AND KNOWTO CONSULT THE DOCTOR BEFORE CONTINUING MEDICATION IF THE PULSE RHYTHM CHANGES KNOW TOA V O I D S M O K I N G A N D S M O K Y E N V I R O N M E N T S A N D P E R S O N S W I T H I N F E C T I O N S E S P E C I A L L Y R E S P I R A T O R Y I N F E C T I O N S
CHF
UNDERSTAND THAT HYPERTENSION IS A CHRONIC DISEASE REQUIRING LIFE LONG TREATMENT EXHIBIT BLOODPRESSURE READINGS CONSISTENTLY WITHIN NORMAL OR SPECIFIED RANGE DEMONSTRATE ADHERENCE TO ALOW-SALT LOW-FAT DIET
Hypertension
HELP THE PATIENT ACHIEVE PAIN RELIEVE AND REDUCE ANGINA EPISODES UNDERSTAND THE CAUSE OFANGINA PECTORIS AND POSSIBLE PRECIPITATING FACTORS FOR AN ATTACK IDENTIFY PERSONAL STRESSORSTHAT MAY CONTRIBUTE TO THE PROBLEM AND BEGIN ELIMINATING OR MINIMIZING THEM KNOW WAYS TOREDUCE THE FREQUENCY OF ANGINA EPISODES
Angina
HEALED DECUBITUS WITHOUT INFECTION OR COMPLICATIONS DEMONSTRATE PROPER DECUBITUS CARE
Alzheimers
UNDERSTAND SS OF BRONCHITIS OR OTHER RESPIRATORY INFECTION AND DISEASE EXACERBATIONUNDERSTAND THE DANGERS OF SMOKING AIR AND CHEMICAL POLLUTANTS AND RESPIRATORY INFECTIONUNDERSTAND AND PRACTICE COUGHING AND DEEP-BREATHING EXERCISES
Respiratory
DAILY COMPLIANCE WCATHETER CARE DECREASE RISK OF URINARY INFECTIONCatheter
INCREASED PAIN RELIEF INCREASED STRENGTH AND ENDURANCE COMPREHEND AND DEMONSTRATE HOME EXERCISEOsteoarthritis
AIDE - GOALS
GAIT PATTERN ENDURANCE STRENGTH AND BALANCE WILL IMPROVE AND PATIENT WILL DEMONSTRATECORRECT BODY MECHANICS WIN 4-6 WKS PTCG WILL COMPREHEND AND DEMONSTRATE HOME EXERCISEPROGRAM WITHIN 4-6 WKS
FAIR-TO BE ABLE TO CARRY OUT MINIMAL ADLS WITH AVAILABLE HOME SUPPORTWILL NOT BE ABLE TO CARRY OUT ADLS WITHOUT MAXIMUM SUPPORT
RETURN TO INDEPENDENT AMBULATION BE SAFE IN SELF CAREPATIENT WILL BE ABLE TO FUNCTION WITH ASSISTANCE OF CAREGIVERWITHIN HESHE CURRENT LIMITATIONS AT HOME
PATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HISHER CURRENT LIMITATIONS AT HOME
PT - GOALS
GOOD RETURN TO PREVIOUS LEVEL OF ADLS INDEPENDENTLY
GAIT PATTERN ENDURANCE STRENGTH AND BALANCE WILL IMPROVE AND PT WILL DEMONSTRATECORRECT BODY MECHANICS WITHIN _____ WEEKS
PATIENT WILL EXPERIENCE A DECREASE IN PAIN
PTCG WILL COMPREHEND AND DEMONSTRATE HOME EXERCISEPROGRAM WITHIN _____ WEEKS
OT PATIENT WILL EXHIBIT IMPROVEMENT IN COPING IN ADLSIADLS MUSCLE USEMOTORCOORDINATIONNEURO RESPONSEUSE OF ORTHOTIC SPLINTING ANDOR EQUIPMENT
OT - GOALS
PATIENT WILL DEMONSTRATE FUNCTIONAL COMMUNICATIONS EXHIBIT MAXIMUM VERBAL AND SENTENCEFORMULATION AND COMPREHENSION WITHIN DISEASE LIMITS WITHIN _____ WEEKS
ST - GOALS
PATIENT WILL DEMONSTRATE APPROPRIATE USE OF FUNCTIONAL VERBALNON-VERBALCOMMUNICATIONS SYSTEMS WITHIN _____ WEEKS
PATIENT WILL DEMONSTRATE IMPROVED READINGWRITING USE OF GESTURESNUMBERS WITHIN _____ WEEKS
PATIENT WILL DEMONSTRATE IMPROVED SWALLOWINGCHEWINGORALMOTOR CONTROL WITHIN _____ WEEKS
PATIENT WILL HAVE ADEQUATE SUPPORT TO REMAIN IN HOME WITH ASSISTANCE OF COMMUNITYRESOURCES FOR FINANCIAL TRANSPORTATION AND PERSONAL CARE ASSISTANCE WITHIN _____ WEEKS
MSW - GOALSPSYCHOSOCIAL EVALUATION WILL BE PERFORMED PTCG WILL BE COUNSELED REGARDING MANAGEMENTamp ADJUSTMENT TO ILLNESS LONG TERM PLANNING AND DECISION MAKING APPROPRIATE COMMUNITYRESOURCE REFERRALS WILL BE MADE
WILL DISCHARGE THE PATIENT WITHIN 60 DAYS WHEN PATIENT ANDORCAREGIVER ISARE ABLE TO DEMONSTRATE KNOWLEDGE OF DISEASE MANAGEMENT SS COMPLICATIONSPATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HISHER CURRENT LIMITATION AT HOME
ABLE TO REMAIN IN HOMERESIDENCEALF WITH ASSISTANCE OF PRIMARY CAEGIVERSUPPORT AT HOMEABLE TO UNDERSTAND MEDICATION REGIMEN AND CARE RELATED TO HISHER DISEASEWILL BE DISCHARGE WHEN MAXIMUM FUNCTIONAL POTENTIAL REACHED
Patient Name Med Record
wwwpnsystemcom 3058185940 The Outcome and Assessment Information Set (OASIS) is the intellectual property of the Center for Health Services and Policy Research Denver Colorado It is used with permission Expiration date 7312012
XPatient Signature if required optional if itinerary is used
SA
LUD
HO
ME
CA
RE
wwwpnsy
stemco
m
3058
1859
40
- OASIS_C_SOC
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- PT ID PERFORMED VIA NAME DOB FACE RECOGNITION AND ADDRESS BEFORE SERVICE PROVIDED Off
- TIME IN
- TIME OUT
- Agency Name SALUD HOME CARE INC
- Phone 305-555-5555
- Employees NameTitle Completing the OASIS
- who has signed the plan of care
- Physician name
- Address 1
- Address 2
- Phone Number
- Address 1_2
- Address 2_2
- Patient Phone
- Reason
- Name
- Other Physician if any
- Phone_2
- Address 1_3
- Address 2_3
- Phone Number_2
- REFERRAL SOURCE if not from Primary Physician
- undefined_6
- Phone_3
- Fax
- Evacuation Form needed Emergency Reg 1
- Evacuation Form needed Emergency Reg 2
- EMERGENCY CONTACT
- Address
- Comments 1
- Comments 2
- Phone_4
- Relationship
- OTHER
- Comment 1
- Comment 2
- 11 Other specify
- a
- b
- 7 Other specify
- c
- d
- e
- f
- a_2
- b_2
- d_2
- e_2
- f_2
- a_3
- b_3
- d_3
- Comment if needed 1
- Comment if needed 2
- a_4
- a_5
- a_6
- Date 23
- undefined_7
- undefined_8
- b_4
- b_5
- b_6
- Date_2
- undefined_9
- undefined_10
- Date_3
- undefined_11
- undefined_12
- d_4
- d_5
- d_6
- Date_4
- undefined_13
- undefined_14
- Date_5
- undefined_15
- undefined_16
- Date_6
- undefined_17
- undefined_18
- 12 1
- 12 2
- Date_7
- undefined_19
- undefined_20
- Date_8
- undefined_21
- undefined_22
- MAIN REASON FOR HOME HEALTH CARE 1
- MAIN REASON FOR HOME HEALTH CARE 2
- Fractures site
- Surgeries site
- Cancer site
- Open Wound site
- Decubitus site
- Other specify
- Other
- Pending or Needed
- Yes Number of times
- Reason s Dates
- MobilityAmbulatory devices used
- Other specify_2
- undefined_23
- Comments if needed 1
- Comments if needed 2
- Comments if needed 3
- Comments if needed 4
- undefined_24
- Name_2
- Phone number if different from patient
- Relationshiphealth statusability to help 2
- Any paid help explain
- Specify 1
- Specify 2
- Specify 3
- Any ears surgeryprocedure
- Date_9
- Otherspecify 1
- Otherspecify 2
- Other agencies involved in care 1
- Other agencies involved in care 2
- 1
- 2
- Other_2
- Infections
- Cataract surgery Site
- Date_10
- Other eyes surgery Site
- Date_11
- explain 1
- explain 2
- Any nose surgery
- Date_12
- Other specify_3
- 1_2
- 2_2
- MassesTumors site
- Lesions explain
- Any surgeryprocedure
- Other specify 1
- Other specify 2
- Other specify 3
- Date_13
- Other specify_4
- No Problem
- Medication
- Other_3
- Pain control treatmentmeds Side effect mark
- Other_4
- Is there a regular pattern to the pain explain
- Other_5
- Comment
- What was the outcome
- Type II OnsetExacerbation date
- DietOral control specify
- INSULIN dosage frequency scale explain
- 1_3
- 2_3
- Since
- Other_6
- A1c
- BS
- mgdL DateTime
- Blood sugar ranges
- site 1Location site
- site 2Location site
- site 3Location site
- Frequency
- Other_7
- site 1New Onset Exacerbation
- site 2New Onset Exacerbation
- site 3New Onset Exacerbation
- Able to use Glucometer
- site 1Present level 010
- site 2Present level 010
- site 3Present level 010
- Diabetes Management Problems explain 1
- Diabetes Management Problems explain 2
- Other Endocrine problems
- site 1Occasional y Cont Intermittent Frequency Frequently
- site 2Occasional y Cont Intermittent Frequency Frequently
- site 3Occasional y Cont Intermittent Frequency Frequently
- site 1Pain type ach ng burn ng rad ating neura gia etc
- site 2Pain type ach ng burn ng rad ating neura gia etc
- site 3Pain type ach ng burn ng rad ating neura gia etc
- Anemia specify type if known
- site 1Feeling of pain internal external acute chronic
- site 2Feeling of pain internal external acute chronic
- site 3Feeling of pain internal external acute chronic
- site 1Pain is worse morning
- site 2Pain is worse morning
- site 3Pain is worse morning
- Immunodeficiency problems explain
- Other 1
- Other 2
- Other_8
- explain 1_2
- explain 2_2
- explain 3
- explain 4
- Other specify 1_2
- Other specify 2_2
- undefined_25
- undefined_26
- undefined_27
- undefined_28
- undefined_29
- undefined_30
- undefined_31
- undefined_32
- undefined_33
- undefined_34
- undefined_35
- undefined_36
- M1310 Pressure Ulcer Length Longest length headtotoe
- undefined_37
- cm
- greatest width perpendicular to the length
- M1314 Pressure Ulcer Depth Depth of the same pressure ulcer from
- cm_2
- visible surface to the deepest area
- undefined_38
- cm_3
- 1_4
- 2_4
- 3_2
- Other_9
- 4_2
- Caregiver name
- Other_10
- cant integument findings
- Observation
- Observation_2
- Caregiver name_2
- Other_11
- Wound cleaned with specify
- Wound irrigated with specify
- 1 Size
- cm width
- Wound packed with specify
- Location
- Other_12
- Wound dressingcover applied specify
- 2 Size
- cm width_2
- Comments 1_2
- Comments 2_2
- Location_2
- Other_13
- Sizecm LengthxWidthxDepth
- Sizecm LengthxWidthxDepth_2
- Diagram 4Sizecm LengthxWidthxDepth
- Tunneling Undermining cm
- Tunneling Undermining cm_2
- Diagram 4Tunneling Undermining cm
- Stage IIIIIIIV pressure uIcers only
- Diagram 4Stage IIIIIIIV pressure uIcers only
- Odor Fool normal etc
- Diagram 4Odor Fool normal etc
- Edema pedal sacral p tting etc
- Diagram 4Edema pedal sacral p tting etc
- Appearance of the Wound Bed
- Diagram 4Appearance of the Wound Bed
- Treatment Ordered
- Diagram 4Treatment Ordered
- Other_14
- Other_15
- Other_16
- Other_17
- Yes 1
- Yes 2
- Yes 3
- Height
- Weight
- Radiating to
- GainLoss
- lb X
- Frequencyduration
- Sittinglying R
- L
- Standing R
- L_2
- Medication_2
- Temperature
- Other_18
- Apical
- Brachial
- Radial
- Carotid
- Dependent
- Pitting 1234
- Respirations
- Site
- Cramps site
- Disease Management Problems explain
- Right Upper
- Right
- Right Lower
- 1_5
- 2_6
- 3_3
- Left
- Left Upper
- Left Lower
- Pacemaker Date
- Last date checked
- SOB on minimal effortwalk
- Type
- fy
- Other Prob 1
- Other Prob 2
- O2
- Trach sizetype
- CaregiverfamilyOther
- Yes explain 1
- Yes explain 2
- Other_19
- Comments 1_3
- Comments 2_3
- Increase fluids
- Restrict fluids
- Frequency_2
- Amount
- Yes describe 1
- Yes describe 2
- Frequency_3
- Other 1_2
- Other 2_2
- Nocturia x
- Bowel Off
- undefined_52
- Diapersother
- Other_20
- No
- 2TOTAL
- Urinary Catheter Type
- Last changed on
- Foley inserted date
- with
- Inflated balloon with
- Irrigation solution Type specify
- Amount_2
- mL Frequency
- Returns
- No_2
- 1_6
- 2_7
- Describe at risk intervention and plan 1
- Describe at risk intervention and plan 2
- Describe at risk intervention and plan 3
- DischargeDrainage describe
- Lesions
- Blisters
- Masses
- Cysts
- Wart
- Other specify_5
- Surgical alteration
- Prostate problem BPH TURP Date
- undefined_53
- undefined_54
- Selftesticular exam Frequency
- Hysterectomy Date
- undefined_55
- undefined_56
- Date last PAP
- undefined_57
- undefined_58
- Results
- Breast selfexam frequency
- Mastectomy R L Date
- undefined_59
- undefined_60
- Other specify_6
- Last BM
- Diarrhea Frequency
- Bowel regimeprogram
- Incontinence Off
- Urinary Off
- Diapersother_2
- Other_21
- te describe skin around stoma
- Ileostomycolostomy s 2
- Ileostomycolostomy s 3
- Ileostomycolostomy s 4
- Ileostomycolostomy s 5
- Headache Location
- Frequency_4
- Other_22
- Migraine Frequency
- Site_2
- Weakness UE LE Location
- Other specify_7
- Site_3
- IV
- Pump typespecify
- Hand grips Equal Unequal specify
- Feedings Type amtrate
- Strong Weak specify
- Psychotropic drug use specify
- Flush Protocol amtspecify
- DoseFrequency
- Other_23
- Other specify 1_3
- Other specify 2_3
- DressingSite care specify 1
- DressingSite care specify 2
- Interventions instructionsComments 1
- Interventions instructionsComments 2
- Following Un
- versalStandard precautions
- NA
- No Problem_2
- Pain Frequency
- Abdominal girth
- Bowel sounds active absent hypo hyperactive x
- 3 Forgetful Off
- 4 Depressed Off
- 6 Lethargic Off
- 5 Disoriented Off
- 7 Agitated Off
- 2 Comatose
- 8 Other Off
- Forgetful at times Off
- Irritable Off
- Anxious Off
- Alert Off
- Describe 1
- Describe 2
- undefined_61
- Needs interpreter
- Comments 1_4
- Comments 2_4
- Higher Educational Level
- Fracture location
- Swollen painful joints specify
- Explain
- Contractures Joint
- Spiritual resource
- Location_3
- Phone No
- Atrophy
- Other_27
- Explain 1
- Explain 2
- Decreased ROM
- Paresthesia
- Weakness
- Other_28
- Inappropriate followthrough in past
- Amputation BKAKUE RL specify 1
- Amputation BKAKUE RL specify 3
- Amputation BKAKUE RL specify 4
- Treatment
- Treatment_2
- Other specify 1_4
- Other specify 2_4
- History of Falls past 3 months 12 falls M1032
- V s on Status Poor w or w o glasses M1200
- Vision Status Poor Legally blind M1200
- Gait and Balance Balance problem while standing
- Gait and Ba ance Balance problem while walking
- Gait and Balance Decreased muscular coordination
- Pred spos ng D seases 12 present
- Predisposing D seases 3 or more present
- Equipment Issues Oxygen tubing
- 1Row1
- PlanComments 1
- PlanComments 2
- Comment_2
- undefined_62
- b Ambulation
- c Transfer
- DOther specify
- 7Independent in home 1
- 7Independent in home 2
- Other 1_3
- Other 2_3
- Typebrand
- Size
- Gauge
- Length
- Insertion site
- Insertion date
- Flush solution
- Frequency_5
- Injection cap change frequency
- Dressing change frequency
- Other_29
- Siteskin condition
- External catheter length
- OtherComment
- fluid overload Other
- Circumference of arm
- Huber gaugelength
- Yes date
- Last flushed date
- Siteskin condition_2
- Infusion solution typevolumerate
- Dressing
- OtherComment 1
- OtherComment 2
- Drug Name
- Dose
- Route
- Frequency_6
- Duration of therapy
- Drug Name_2
- Dose_2
- Route_2
- Frequency_7
- Duration of therapy_2
- CommentPlan 1
- CommentPlan 2
- Pump type specify
- Other_30
- Lab draws
- Infusion care provided during visit 1
- Infusion care provided during visit 2
- Infusion care provided during visit 3
- Antibiotic therapy
- 1_7
- 2_8
- Other_31
- Removing line date if know
- BraceOrthotics specify 1
- BraceOrthotics specify 2
- BraceOrthotics specify 3
- Needs specify 1
- Needs specify 2
- Oxygen HME Co
- Prosthesis RUE RLE LUELLEOther
- HME Rep
- Grab bars BathroomOther
- Hospital bed Semielec Crank Spec
- Other_32
- NA_2
- Phone_5
- n care
- PlanComments
- N
- Other_33
- undefined_63
- Physical Therapy Total visits
- Speech Therapy Total visits
- visits
- Other Therapy Total visits
- Patient is not assessed to be at risk for falls
- No pain identified
- Patient has no pressure ulcers with need for moist wound healing
- O
- Noncompliance with drug orders
- Expected Outcome
- Patient unable to perform own Wound Care due
- Pat
- to
- Abd Pads Off
- Underpads size
- undefined_68
- Special mattress overlay
- Angiocatheter size
- Ostomy pouch brand size
- Pressure relieving device
- Ostomy wafer brand size
- undefined_69
- SYRINGES
- Batteries size
- Skin protectant
- Glucometer
- Hydrocolloids
- undefined_70
- FOLEYCATH SUPPLIES
- Syringes size
- size
- Oxygen concentrator
- Feeding tube
- Ointment
- Acetic acid
- Other 1_4
- Other 2_4
- Other 3
- Tens unit
- KLING 4
- Other 1_5
- Other 2_5
- Other 3_2
- PatientCG educationteaching this visit for
- MEDICATION Off
- DISEASE PROCESS COMPLICATIONS Off
- undefined_71
- SS OF Off
- ILEAL CONDUITOSTOMY Off
- DIET FLUIDS Off
- undefined_72
- undefined_73
- SKINFOOT CARE Off
- INFECTION CONTROL Off
- OTHER INSTRUCTIONS GIVEN
- Caregiver present during the visit
- NEEDS FURTHER TEACHING Off
- No_3
- Skilled Observation Assessment
- ent Educat
- Wound Care Dress
- Diabetic Observation Care
- Correct handwashing technique followed SG 1
- Correct handwashing technique followed SG 2
- Correct handwashing technique followed SG 3
- Correct handwashing technique followed SG 4
- 21 Included as reference only your Professional Staff must reviewupdatepersonalizedapprove the orders
- SN ORDERS FREQUENCYDURATION
- S COMPLICATIONS
- TH GLUCOMETER OR
- ON
- TEACH GLUCOMETER OR
- NSERTION
- TH
- INST DRESSING CHANGES
- MONITOR STATUS OF WOUND OR DECUBITUS place
- ADMINISTER PRESCRIBED INJECTABLE
- USING
- TH_2
- TH_3
- AND APPLY
- CLEANSE WOUND WITH
- NSE WITH
- AND APPLY_2
- OTHER_2
- DE ORDERS FREQUENCYDURATION
- PT ORDERS FREQUENCYDURATION
- OT ORDERS FREQUENCYDURATION
- ST ORDERS FREQUENCYDURATION
- MSW ORDERS FREQUENCYDURATION
- Included as reference only your Professional Staff must reviewupdatepersonalizeapprove the goals 22
- MRMS
- PROGRAM WITHIN
- CORRECT BODY MECHANICS WITHIN
- COMMUNICATIONS SYSTEMS WITHIN
- undefined_75
- undefined_76
- Date_14
- QA Date Reviewed
- undefined_77
- undefined_78
- Data Entry Date Locked
- undefined_79
- undefined_80
- Date Submitted
- undefined_81
- undefined_82
- SOCD
- SOCM
- SOCY
- SOCM1
- SOCD1
- SOCY1
- Check Box2 Off
- Check Box3 Off
- Check Box4 Off
- TOM
- TOD
- TOY
- FDM
- FDD
- FDY
- Prov 1071523
- BrID
- Check Box9 Yes
- BrIDno
- Check Box11 Off
- DLCM
- DLCD
- DLCY
- LVM
- LVD
- LVY
- DNR1 Off
- Check Box19 Off
- STFL
- PZC
- MCN
- NOMC Off
- SSN1
- SSN2
- SSN3
- SSUK Off
- MAN
- MAUK Off
- DOBM
- DOBD
- DOBY
- SEX Off
- MR
- First
- MI
- Last
- Suffix
- RACE2 Off
- RACE3 Off
- RACE4 Off
- RACE5 Off
- RACE1 Off
- RACE6 Off
- PS3 Off
- PS0 Off
- PS1 Off
- PS4 Off
- PS5 Off
- PS6 Off
- PS7 Off
- PS8 Off
- PS9 Off
- PS10 Off
- PS11 Off
- PS2 Off
- PSUK Off
- Ecode
- COMP Off
- DACM
- DACD
- DACY
- REA Off
- DM
- DD
- DY
- RDM
- RDD
- RDY
- REFDM
- REFDD
- REFDY
- EPT Off
- 14D2 Off
- 14D3 Off
- 14D4 Off
- 14D5 Off
- 14D6 Off
- 14D7 Off
- 14D8 Off
- Check Box39 Off
- icd9c
- icd9a
- icd9b
- icd9d
- icd9e
- icd9f
- Check Box5 Off
- Check Box7 Off
- icd9b2
- icd9c2
- icd9d2
- C_2
- icd9e2
- icd9f2
- icd9a2
- icd9b3
- icd9c3
- C_3
- icd9a3
- icd9d3
- 1005d
- 1005m
- 1005y
- 1018-2 Off
- 1018-1 Off
- 1018-4 Off
- 1018-5 Off
- 1018-6 Off
- 1018-7 Off
- 1018-NA Off
- 1018-UK Off
- 1018-3 Off
- 1012-na Off
- 1012-uk Off
- Radio Button11 Off
- v1020b
- C_5
- e_5
- f_5
- C_6
- e_6
- f_6
- c_4
- e_4
- f_4
- v1020c
- v1020d
- v1020e
- v1020f
- v1020a
- e1020b
- e1020c
- e1020d
- e1020e
- e1020f
- e1020a
- ev1020b
- ev1020c
- ev1020d
- ev1020e
- ev1020f
- ev1020a
- sp12-1
- sp12-2
- Radio Button12 Off
- Radio Button13 Off
- rad0 Off
- rae0 Off
- rdf0 Off
- phhp Off
- phrp1 Off
- phot1 Off
- phoa1 Off
- phfc1 Off
- phca1 Off
- phin1 Off
- phga1 Off
- phif1 Off
- phsg1 Off
- phwd1 Off
- phdc1 Off
- phgn1 Off
- rddmi Off
- imin Off
- inh1n1 Off
- fwpn Off
- fwtn Off
- fwot Off
- phdm1 Off
- PHNY Off
- phcd1 Off
- 10304 Off
- 10301 Off
- 10302 Off
- 10303 Off
- 10327 Off
- M1034 Off
- HBR1 Off
- HBR2 Off
- HBR3 Off
- HBR4 Off
- HBR5 Off
- HBR6 Off
- HBR7 Off
- HBR8 Off
- HBR9 Off
- HBR11 Off
- HBR12 Off
- HBR10 Off
- HBR13 Off
- SOBFT
- 10321 Off
- 10322 Off
- 10333 Off
- 10324 Off
- 10325 Off
- 10336 Off
- M11001 Off
- M1100b Off
- M1100c Off
- Relationshiphealth statusability to help 1
- 10361 Off
- 10362 Off
- 10363 Off
- 10364 Off
- 10365 Off
- 10366 Off
- 1210d Off
- 1210an Off
- 1210hea Off
- 1210OTH Off
- 1210TIN Off
- 1210NP Off
- 12102 Off
- 12101 Off
- 1210uk Off
- 1210h Off
- 1210v Off
- 1200CAT Off
- 1200OTH Off
- 1200JA Off
- 1200CATRL Off
- 1200OTHER Off
- 1200PT Off
- 1200GLAU Off
- 1200NOP Off
- NOSECON Off
- NOSEEP Off
- NOSELS Off
- NOSESINP Off
- NOSEASG Off
- NOSEOTHSP Off
- NOSENP Off
- THROATDY Off
- TROATL Off
- THROATOTH Off
- 1200BV Off
- 1200LB Off
- THROATHO Off
- THOATSO Off
- THROATNP Off
- 1200GL Off
- 1200CO Off
- 1200PR Off
- 1200IN Off
- M1200 Off
- M1220 Off
- M1230 Off
- MOUTHMas Off
- MOUTHGI Off
- MOUTHULC Off
- MOUTHTOO Off
- MOUTHANY Off
- MOUTHOTH Off
- MOUTHNP Off
- M1240 Off
- M1242 Off
- MOUTHDE Off
- MOUTHUP Off
- MOUTHLO Off
- MOUTHPAR Off
- COPYN Off
- MKMEDP Off
- CPCYN Off
- DPRYN Off
- ICPYN Off
- TURGGP Off
- BESTPAINSC2
- WORSES2
- BESTPAINSC
- WORSESC
- BESTPAINSC3
- WORSESC3
- FACESOBS Off
- SCALE010 Off
- WPSL Off
- WPMA Off
- WPMV Off
- WPAMB Off
- WPIMM Off
- WPTR Off
- WPOTH Off
- WPNP Off
- NVIM Off
- WRP4 Off
- WRP5 Off
- WRP6 Off
- WRP7 Off
- WRP8 Off
- WRP9 Off
- WRPOTH Off
- TKMEDNV Off
- TKMEDLDD Off
- TKMEDD Off
- TKMED23 Off
- TKMEDLT3 Off
- PCTSL Off
- PTXSEN Off
- PTXSEV Off
- PTXSECF Off
- PRDOCC Off
- PTXSEOTH Off
- PRDCONT Off
- WRP1 Off
- WRP2 Off
- WRP3 Off
- PRDINT Off
- PRDFRQ Off
- PHYNOTPT Off
- PHYNOTSTF Off
- NVIG Off
- NVIC Off
- NVIAF Off
- DMIJUV Off
- DMTPII Off
- INSDGFQ Off
- DMODIET Off
- ADMOTH Off
- symphyg Off
- sympfat Off
- symhypog Off
- endopcgr Off
- endopostpra Off
- endorand Off
- endolab Off
- bsrange Off
- bsranptcg Off
- endomonsf Off
- endomoncg Off
- endomonsn Off
- endomonoth Off
- dmNapb Off
- othendopb Off
- enlthyr Off
- intoheatcol Off
- endonp Off
- HEMAANE Off
- HEMABLEED Off
- HEMAHEMO Off
- HEMAINMO Off
- HEMAOTH Off
- HEMANP Off
- SKINITCH Off
- SKINRASH Off
- SKINDRY Off
- SKINSCL Off
- SKINRED Off
- SKINBRU Off
- SKINECCH Off
- SKINPALL Off
- SKINJAU Off
- ADMSELF Off
- ADMSCGF Off
- ADMNURS Off
- SKINNP Off
- m1300 Off
- M1302 Off
- M1306 Off
- M1320 Off
- M1322 Off
- M1324 Off
- M1330 Off
- M1332 Off
- M1334 Off
- M1340 Off
- M1342 Off
- M1350 Off
- WCPYN Off
- IPDMYN Off
- APHYN Off
- SDRBY Off
- SDRSN Off
- SDRCG Off
- SDRPT Off
- SDROTH Off
- TECST Off
- TECCL Off
- WDCLW Off
- WDIRRW Off
- WDPKW Off
- WDDREW Off
- DBFEXD Off
- DBFEX2D Off
- DBFEXEOD Off
- DFEX2WK Off
- DBNFEXWK Off
- DFEXOTH Off
- PDPPRL Off
- PDPARL Off
- LSWRL Off
- endobm Off
- endotv Off
- fbs Off
- LSCDRL Off
- ASCCFR Off
- ASCCFL Off
- Right for
- ASCCFLF
- TRINR Off
- BURRL Off
- LEGHP Off
- LEGHAB Off
- DBFEXRN Off
- DFEXCG Off
- DBFEXPT Off
- DBFEXOT Off
- EXSER Off
- EXSERG Off
- EXSANG Off
- EXSER2 Off
- EXSERG2 Off
- EXSANG2 Off
- SHOV Off
- SHAPRD Off
- SHAPOTH Off
- SHOV2 Off
- SHAPRD2 Off
- SHAPOTH2 Off
- cm length
- cm length2
- DBFTEXRNPT Off
- EXDYN Off
- EXDYN2 Off
- APHYN2 Off
- APHYN3 Off
- Loc3w
- Loc2w
- Loc1w
- Loc4w
- Typew1
- Typew2
- Typew3
- Typw4
- sizw3
- tunnw3
- surrw1
- stomaw1
- surrw1a
- stomaw1a
- surrw3
- surrw3a
- stomaw3
- stomaw3a
- surrw2
- surrw2a
- stomaw2
- stomaw2a
- surrw4
- surrw4a
- stomaw4
- stomaw4a
- statgew2
- statgew3
- Odorw2
- Odorw3
- Edemaw2
- Edemaw3
- appw2
- appw3
- Treatment Ordered_2
- Treatment Ordered_3
- Group10 Off
- draick2 Off
- driack3 Off
- draick4 Off
- colw11 Off
- colw12 Off
- colw31 Off
- colw32 Off
- colw33 Off
- colw34 Off
- colw21 Off
- colw22 Off
- colw23 Off
- colw24 Off
- colw43 Off
- colw44 Off
- ital1u1 Off
- ital1u2 Off
- fsrrepo Off
- frsact Off
- rwgchpt Off
- rwgchcgf Off
- rwgchnur Off
- pulreg1 Off
- pulirreg1 Off
- fsrrespreg Off
- colw41 Off
- colw42 Off
- bpsitly Off
- bpstand Off
- fsrwgrep Off
- fsrwgact Off
- tempaxil Off
- temptymp Off
- pulseappical Off
- pulseradial Off
- pulsebrach Off
- pulsecarot Off
- pulserest Off
- pulsecheyn Off
- pulseactiv Off
- respirirreg Off
- respideath Off
- respaccess Off
- respiapnea Off
- bsckrack Off
- temporal Off
- temprect Off
- chestprad Off
- colw13 Off
- colw14 Off
- consth2 Off
- consthic2 Off
- consth3 Off
- consthic3 Off
- consth4 Off
- consthic4 Off
- chestpyes Off
- chestpainno Off
- consth1 Off
- consthic1 Off
- cpsubstern Off
- cpviselike Off
- dm5lin
- assocwithsoboe Off
- associawactv Off
- associwsweat Off
- cphowreloth Off
- cphowrelrest Off
- cphowrelmeds Off
- cppalarr Off
- cppalpfast Off
- cppalpslow Off
- cppalpfatig Off
- cpedema Off
- cpedemapedal Off
- cpangina Off
- cppostural Off
- cplocalized Off
- cpedempedrig Off
- cpedemapedallef Off
- cpedemasacral Off
- cpedemadepend Off
- cpedemapitt Off
- cpedemanonpitt Off
- cstcramp Off
- cardstclaud Off
- cardstcapref Off
- cstcaprefless Off
- castcaprefgreat Off
- csthsreg Off
- csthsirreg Off
- csthsmurmur Off
- cstpacemak Off
- cpstabreassouclear Off
- breassodwheez Off
- bresddimm Off
- chestpaidull Off
- cpache Off
- cpsharp Off
- brsdabset Off
- brsdsobsoboe Off
- brsdsobonmineff Off
- 14001 Off
- 14003 Off
- 14004 Off
- 1400tva Off
- 14002 Off
- 1400car Off
- 14101 Off
- 14102 Off
- 14103 Off
- 14104 Off
- uroops Off
- uropat Off
- urocare Off
- 14000 Off
- urosn Off
- Radio Button2 Off
- 16100 Off
- 16101 Off
- 1400pat Off
- 16concar Off
- 162gm Off
- 16nas Off
- 16npo Off
- 16102 Off
- 161800cal Off
- 16lowfat Off
- 16lowcho Off
- 16incflu Off
- 16restflu Off
- 16exc Off
- 16good Off
- 16fair Off
- 16poor Off
- 16anore Off
- 16nau Off
- 16vom Off
- 16heabur Off
- O2satur
- O2firesaf Off
- O2sn Off
- O2carefamother Off
- O2cough Off
- O2no Off
- O2yes Off
- O2nonprod Off
- O2noc Off
- O2yesc Off
- O2dys Off
- O2rest Off
- O2dADL Off
- O2sliplo Off
- O2nop Off
- O2yesp Off
- 16other Off
- genibur Off
- genihes Off
- genihema Off
- geniolig Off
- geniurg Off
- geninoc Off
- geniincon Off
- geniuri Off
- genidiap Off
- 16lowna Off
- genicyell Off
- genicamber Off
- genicbr0 Off
- genicbt Off
- genicother Off
- genicla Off
- geniclo Off
- genised Off
- geniodno Off
- genifol Off
- geniwitdif Off
- genisup Off
- geniyes Off
- genino Off
- 1620 Off
- 1615 Off
- 1630 Off
- 1630cosn Off
- 1630lBM Off
- 1630diar Off
- 1630rect Off
- 1630hemo Off
- 1630incon Off
- 1630diap Off
- 1630lax Off
- 1630w Off
- 1630d Off
- 1630m Off
- 1630lleost Off
- 1630pat Off
- 1630car Off
- 1630sn Off
- 1630ot Off
- 1630np Off
- 1630follow Off
- genblis Off
- genmass Off
- gencys Off
- genwart Off
- geninf Off
- gensurg Off
- genprost Off
- gensef Off
- genmeno Off
- genhyst Off
- gendisc Off
- geniodyes Off
- gennp Off
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