OCCUPATIONAL THERAPY COMPREHENSIVE ADULT ASSESSMENT

Name of Emergency Contact:_________________________________________

Relationship:________________________________________________________

Phone:____________________________

Address:___________________________________________________________

City:__________________________ State:______ ZIP Code:_______________

Email:______________________________________________________________

Medical Record Number if different from Patient ID Number

______________________________________________________________

(M0030) Start of Care Date:

(M0032) Resumption of Care Date:❑ NA - Not Applicable

❑ Physician ordered ROC date ❑ Fixed 48-hours post 24-hour hospitalization

for any reason other than diagnostic tests

(M0040) Patient Name:

(First) (MI)

(Last) (Suffix)

Patient Phone:____________________________

Patient Email:_______________________________________________________

Patient Address:

____________________________________________________________________(Street/Apt. No.)

________________________________________________________(City)

(M0050) Patient State of Residence:

(M0060) Patient ZIP Code:

(M0063) Medicare Number: ❑ NA - No Medicare

(including suffix)

(M0064) Social Security Number: ❑ UK - Unknown or Not Available

(M0065) Medicaid Number: ❑ NA - No Medicaid

(M0066) Birth Date:

PA ★P HH

PATIENT NAME–Last, First, Middle Initial ID#

OCCUPATIONALTHERAPY ASSESSMENT

with OASIS ELEMENTS of 27

Form 3498P-18 © 2018 BRIGGS (800) 247-2343 www.BriggsHealthcare.com. The Outcome and ASsessment Information Set (OASIS)Rev. 1/18 is the intellectual property of the Center for Health Services and Policy Research, Denver, Colorado. It is used with permission.

This Patient Tracking Information must be filled out at start of care and per organizational policy.It is to be maintained as part of the clinical record.

PA ★P R

R

HH

month day year/ /

month day year/ /

- -

-

month day year/ /

(M0010) CMS Certification Number:

Branch Identification (M0014) Branch State:

(M0016) Branch ID Number:

(M0018) National Provider Identifier (NPI) for the attending physicianwho has signed the plan of care:

❑ UK - Unknown or Not Available

Physician Name:______________________________________ ____(First) (MI)

________________________________________________________ _______ (Last) (Suffix)

Physician Phone:____________________________

Physician Fax:____________________________

Physician Email:____________________________________________________

Physician Address: (Street/Suite No.)

___________________________________________________________________


Secondary Physician NPI #:_______________________________

Name:______________________________________ ____(First) (MI)

________________________________________________________ _______ (Last) (Suffix)

Phone:____________________________ Fax:____________________________

Email:______________________________________________________________

Address: (Street/Suite No.)

___________________________________________________________________


Primary Care Practitioner/Practitioner’s Group or other Health Care Professional responsible for providing care/services post-discharge

NPI #:____________________________ Specialty:________________________

Name:______________________________________ ____(First) (MI)

________________________________________________________ _______ (Last) (Suffix)

Phone:____________________________ Fax:____________________________

Email:______________________________________________________________

Address: (Street/Suite No.)

___________________________________________________________________


(M0020) Patient ID Number:

EMERGENCY PREPAREDNESS

★ ★ ★ PRIORITY CODE:_____________________ ★ ★ ★

Does the patient have an Advance Directives order? ❑ No ❑ Yes

DATE:_____________________

TIME IN:___________ TIME OUT:___________

OCCUPATIONAL THERAPYCOMPREHENSIVE ADULT ASSESSMENT

INCLUDING START OF CARE/RESUMPTION OF CAREOASIS ELEMENTS WITH

PLAN OF CARE/485 INFORMATIONR = Risk AdjustmentHH = Home Health ComparePA = Potentially Avoidable Event★ = 5 Star

PERFORMANCE INDICATORS:O = Outcome MeasureP = Process Measure$ = Reimbursement Potential

REASON FOR ASSESSMENT: ❑ Start of Care ❑ Resumption of CareFollow OASIS items in sequence unless otherwise directed.

= Dash is a valid response. See the OASIS C2 Guidance Manualfor the exact instructions for each specific item.

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Certification Period:

From:_______________ To:_______________

Does the patient have a representative? ❑ No ❑ Yes If yes, is the person: ❑ Court declared ❑ Patient selected

Name and Title of Representative:

________________________________________________________________

Representative Mailing Address:

________________________________________________________________


Phone Number(s): Work:___________________________________________

Home:__________________________________________

Cell:____________________________________________

Email:______________________________________________________________

(M0140) Race/Ethnicity: (Mark all that apply.)❑ 1 - American Indian or Alaska Native❑ 2 - Asian❑ 3 - Black or African-American❑ 4 - Hispanic or Latino❑ 5 - Native Hawaiian or Pacific Islander❑ 6 - White

(M0150) Current Payment Sources for Home Care:(Check all that apply)❑ 0 - None; no charge for current services❑ 1 - Medicare (traditional fee-for-service)❑ 2 - Medicare (HMO/managed care/Advantage plan)❑ 3 - Medicaid (traditional fee-for-service)❑ 4 - Medicaid (HMO/managed care)❑ 5 - Workers’ compensation❑ 6 - Title programs (for example, Title III, V, or XX)❑ 7 - Other government (for example, TriCare, VA)❑ 8 - Private insurance❑ 9 - Private HMO/managed care❑ 10 - Self-pay❑ 11 - Other (specify):_____________________________________________❑ UK - Unknown



Patient Name______________________________________________________________________________________________________ ID #________________________________________

Form 3498P-18 © 2018 BRIGGS (800) 247-2343 www.BriggsHealthcare.com. 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.

(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 services,record the date specified.

[Go to M0110, if date entered]

❑ NA - No specific SOC date ordered by physician

(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA.

P

P PA$

O RR

HH

HH

P HH

Enter Code

Enter Code

(M0080) Discipline of Person Completing Assessment

1 RN

2 PT

3 SLP/ST

4 OT

Enter Code

(M0100) This Assessment is Currently Being Completed for theFollowing Reason:

Start/Resumption of Care

1 Start of care –further visits planned

3 Resumption of care (after inpatient stay)

Follow-Up

4 Recertification (follow-up) reassessment [Go to M0110]

5 Other follow-up [Go to M0110]

Transfer to an Inpatient Facility

6 Transferred to an inpatient facility–patient not dischargedfrom agency [Go to M1041]

7 Transferred to an inpatient facility–patient dischargedfrom agency [Go to M1041]

Discharge from Agency – Not to an Inpatient Facility

8 Death at home [Go to M2005]

9 Discharge from agency [Go to M1041]

Enter Code 1 or 3 only when completing this form. Start of Care/Resumption of Care.When ROC, review patient tracking information and complete M0032.

(M0090) Date Assessment Completed:month day year

/ /

month day year/ /

month day year/ /

(M0110) Episode Timing: Is the Medicare home health payment episode for which this assessment will define a case mix group an “early”episode or a “later” episode in the patient’s current sequence of adjacent Medicare home health payment episodes?

1 Early2 LaterUK Unknown

NA Not Applicable: No Medicare case mix group to be defined by this assessment.

*Early Episode is first or second episode in a sequence of adjacentepisodes. Later is the third episode and beyond in sequence of adjacent episodes. Adjacent episodes are separated by 60 days orfewer between episodes.

REnter Code

(M0069) Gender

1 Male

2 Female

Patient’s HI Claim No.:

❑ 1 - Same as M0063 ❑ 2 - Same as M0065

❑ 3 - Other:________________________________________________________

CLINICAL RECORD ITEMS

R


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(M1000) From which of the following Inpatient Facilities was thepatient discharged within the past 14 days? (Mark all that apply.)

❑ 1 - Long-term nursing facility (NF)

❑ 2 - Skilled nursing facility (SNF / TCU)

❑ 3 - Short-stay acute hospital (IPPS)

❑ 4 - Long-term care hospital (LTCH)

❑ 5 - Inpatient rehabilitation hospital or unit (IRF)

❑ 6 - Psychiatric hospital or unit

❑ 7 - Other (specify) ____________________________________________

❑ NA - Patient was not discharged from an inpatient facility[Go to M1017]

(M1005) Inpatient Discharge Date (most recent):

❑ UK - Unknown

(M1011) List each Inpatient Diagnosis and ICD-10-CM code at thelevel of highest specificity for only those conditions actively treated during an inpatient stay having a discharge date within the last 14 days(no V, W, X, Y, or Z codes or surgical codes):

Inpatient Facility Diagnosis ICD-10-CM Code

a. ___________________________________

b. ___________________________________

c. ___________________________________

d. ___________________________________

e. ___________________________________

f. ___________________________________



(M1017) Diagnoses Requiring Medical or Treatment RegimenChange Within Past 14 Days: List the patient’s Medical Diagnoses andICD-10-CM codes at the level of highest specificity for those conditions requiring changed medical or treatment regimen within the past 14 days(no V, W, X, Y, or Z codes or surgical codes):

Changed Medical Regimen Diagnosis ICD-10-CM Code

a. ___________________________________

b. ___________________________________

c. ___________________________________

d. ___________________________________

e. ___________________________________

f. ___________________________________

❑ NA - Not applicable (no medical or treatment regimen changes withinthe past 14 days)

(M1018) Conditions Prior to Medical or Treatment Regimen Changeor Inpatient Stay Within Past 14 Days: If this patient experienced aninpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions that existed prior tothe inpatient stay or change in medical or treatment regimen. (Mark allthat apply.)❑ 1 - Urinary incontinence

❑ 2 - Indwelling/suprapubic catheter

❑ 3 - Intractable pain

❑ 4 - Impaired decision-making

❑ 5 - Disruptive or socially inappropriate behavior

❑ 6 - Memory loss to the extent that supervision required

❑ 7 - None of the above

❑ NA - No inpatient facility discharge and no change in medical or treatment regimen in past 14 days

❑ UK - Unknown

Patient Name______________________________________________________________________________________________________ ID #________________________________________


P

P

R

R

R

R HH

HHmonth day year

/ /

PATIENT HISTORY AND DIAGNOSES

PHYSICIAN: Date last contacted:_____________ Date last visited:_____________

PRIMARY REASON FOR HOME HEALTH: (review Face-to-Face)________________________________________________________________________

___________________________________________________________________________________________________________________________________

Certifying physician’s prognosis:______________________________________________________________________________________________________CONFINED TO HOME (homebound): ❑ No ❑ Yes, and the patient either

1. Criteria-One: (must choose at least one)❑ Because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special

transportation; or the assistance of another person in order to leave their place of residence.AND/OR

❑ Have a condition such that leaving his or her home is medically contraindicated.If the patient meets one of the Criteria-One conditions, then the patient must ALSO meet two additional requirements defined in Criteria-Two below.

2. Criteria-Two:❑ There must exist a normal inability to leave home (specify) _________________________________________________________________________

AND❑ Leaving home must require a considerable and taxing effort.

PERTINENT HISTORY AND/OR PREVIOUS OUTCOMES: (note dates of onset, exacerbation when known)(Reference M1000, M1005, M1011 and M1028)

❑ Hypertension ❑ Cardiac ❑ Respiratory ❑ Osteoporosis ❑ Fractures ❑ Cancer (site:______________________________________________)❑ Infection ❑ Immunosuppressed ❑ Open Wound ❑ Surgeries:_____________________________________________________________________

❑ Other (specify):_________________________________________________________________________________________________________________

IMMUNIZATIONS: Within the past 12 months: ❑ Influenza (specifically this year’s flu season October 1 to March 31)

According to immunization guidelines: ❑ Pneumonia ❑ Tetanus ❑ Shingles ❑ Hepatitis C ❑ Other:____________________

Needs:___________________________________________________________________________________________________________

PRIOR HOSPITALIZATIONS: ❑ No ❑ Yes Number of times:_______ Reason(s) /Date(s):__________________________________________________________________________________________________________________________________________________________________________________


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PATIENT HISTORY AND DIAGNOSES (Cont’d)Patient Name______________________________________________________________________________________________________ ID #________________________________________

(M1021) Primary Diagnosis

a.______________________________________________________________________

Date:_____________ ❑ O ❑ E

(M1023) Other Diagnosesb.___________________________________

___________________________________Date:_____________ ❑ O ❑ E

c.______________________________________________________________________

Date:_____________ ❑ O ❑ E

d.______________________________________________________________________

Date:_____________ ❑ O ❑ E

e.______________________________________________________________________

Date:_____________ ❑ O ❑ E

f. ______________________________________________________________________

Date:_____________ ❑ O ❑ E

V, W, X, Y codesNOT allowed

a.

❑ 0 ❑ 1 ❑ 2 ❑ 3 ❑ 4

All ICD-10-C M codes allowed

b.

❑ 0 ❑ 1 ❑ 2 ❑ 3 ❑ 4

c.

❑ 0 ❑ 1 ❑ 2 ❑ 3 ❑ 4

d.

❑ 0 ❑ 1 ❑ 2 ❑ 3 ❑ 4

e.

❑ 0 ❑ 1 ❑ 2 ❑ 3 ❑ 4

f.

❑ 0 ❑ 1 ❑ 2 ❑ 3 ❑ 4

V, W, X, Y, Z codes NOT allowed

a. _____________________________


b. _____________________________

c. _____________________________

d. _____________________________

e. _____________________________

f. _____________________________

(M1021) Primary Diagnosis & (M1023) Other DiagnosesColumn 1 Column 2 Column 3 Column 4

(M1025) Optional Diagnoses (OPTIONAL) (not used for payment)

ICD-10-CM and symptom controlrating for each condition. Notethat the sequencing of these ratings may not match the

sequencing of the diagnoses

May be completed if a Z-code isassigned to Column 2 and the

underlying diagnosis is resolved

Complete only if the OptionalDiagnosis is a multiple coding situation

(for example: a manifestation code)

Diagnoses(Sequencing of diagnoses should reflect theseriousness of each condition and support

the disciplines and services provided)

Description ICD-10-CM /Symptom Control Rating

Description /ICD-10-CM

Description /ICD-10-CM

(M1021/1023/1025) Diagnoses, Symptom Control, and Optional Diagnoses: List each diagnosis for which the patient is receiving home care in Column 1, and enterits ICD-10-CM code at the level of highest specificity in Column 2 (diagnosis codes only - no surgical or procedure codes allowed). Diagnoses are listed in the order thatbest reflects the seriousness of each condition and supports the disciplines and services provided. Rate the degree of symptom control for each condition in Column 2.ICD-10-CM sequencing requirements must be followed if multiple coding is indicated for any diagnoses. If a Z-code is reported in Column 2 in place of a diagnosis that isno longer active (a resolved condition), then optional item M1025 (Optional Diagnoses - Columns 3 and 4) may be completed. Diagnoses reported in M1025 will not impactpayment.Code each row according to the following directions for each column:Column 1: Enter the description of the diagnosis. Sequencing of diagnoses should reflect the seriousness of each condition and support the disciplines and services provided.Column 2: Enter the ICD-10-CM code for the condition described in Column 1 - no surgical or procedure codes allowed. Codes must be entered at the level of highest

specificity and ICD-10-CM coding rules and sequencing requirements must be followed. Note that external cause codes (ICD-10-CM codes beginning with V, W, X,or Y) may not be reported in M1021 (Primary Diagnosis) but may be reported in M1023 (Secondary Diagnoses). Also note that when a Z-code is reported in Column 2,the code for the underlying condition can often be entered in Column 2, as long as it is an active on-going condition impacting home health care.Rate the degree of symptom control for the condition listed in Column 1. Do not assign a symptom control rating if the diagnosis codes is a V, W, X, Y or Z-code.Choose one value that represents the degree of symptom control appropriate for each diagnosis using the following scale:

0 - 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 the rating for symptom control in Column 2 should not be used to determine the sequencing of the diagnoses listed in Column 1. These are separate itemsand sequencing may not coincide.

Column 3: (OPTIONAL) There is no requirement that HHAs enter a diagnosis code in M1025 (Columns 3 and 4). Diagnoses reported in M1025 will not impact payment.Agencies may choose to report an underlying condition in M1025 (Columns 3 and 4) when:

• a Z-code is reported in Column 2 AND• the underlying condition for the Z-code in Column 2 is a resolved condition. An example of a resolved condition is uterine cancer that is no longer being treated

following a hysterectomy.Column 4: (OPTIONAL) If a Z-code is reported in M1021/M1023 (Column 2) and the agency chooses to report a resolved underlying condition that requires multiple diagnosis

codes under ICD-10-CM coding guidelines, enter the diagnosis descriptions and the ICD-10-CM codes in the same row in Columns 3 and 4. For example, if the resolvedcondition is a manifestation code, record the diagnosis description and ICD-10-CM code for the underlying condition in Column 3 of that row and the diagnosis description and ICD-10-CM code for the manifestation in Column 4 of that row. Otherwise, leave Column 4 blank in that row.

Surgical Procedure ICD

______________________________________________________________________________ (_________________________ ) Date:_____________

______________________________________________________________________________ (_________________________ ) Date:_____________

M1021, M1023, M1025 = $ R

❑ Check here if a coder or Business Associate was consulted with to complete ICD coding.

•( )

•( )

•( )

•( )

•( )

•( )


a. _____________________________


b. _____________________________

c. _____________________________

d. _____________________________

e. _____________________________

f. _____________________________

•( )

•( )

•( )

•( )

•( )

•( )


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PATIENT HISTORY AND DIAGNOSES (Cont’d)Patient Name______________________________________________________________________________________________________ ID #________________________________________

(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

(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Markall that apply.)❑ 1 - History of falls (2 or more falls - or any fall with an injury - in the

past 12 months)❑ 2 - Unintentional weight loss of a total of 10 pounds or more in the

past 12 months❑ 3 - Multiple hospitalizations (2 or more) in the past 6 months❑ 4 - Multiple emergency department visits (2 or more) in the past 6

months❑ 5 - Decline in mental, emotional, or behavioral status in the past 3

months❑ 6 - Reported or observed history of difficulty complying with any

medical instructions (for example, medications, diet, exercise) inthe past 3 months

❑ 7 - Currently taking 5 or more medications❑ 8 - Currently reports exhaustion❑ 9 - Other risk(s) not listed in 1 - 8❑ 10 - None of the above

(M1028) Active Diagnoses - Comorbidities and Co-existing Conditions – Check all that applySee OASIS Guidance Manual for a complete list of relevant ICD-10 codes. ❑ 1 - Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD) ❑ 2 - Diabetes Mellitus (DM)


R

RR$

Enter Code

(M1034) Overall Status: Which description best fits the patient’s overallstatus?

0 The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of thepatient’s age).

1 The patient is temporarily facing high health risk(s) but islikely to return to being stable without heightened risk(s)for serious complications and death (beyond those typical of the patient’s age).

2 The patient is likely to remain in fragile health and haveongoing high risk(s) of serious complications and death.

3 The patient has serious progressive conditions that couldlead to death within a year.

UK The patient’s situation is unknown or unclear.

(M1036) Risk Factors, either present or past, likely to affect currenthealth status and/or outcome: (Mark all that apply.)❑ 1 - Smoking❑ 2 - Obesity❑ 3 - Alcohol dependency❑ 4 - Drug dependency❑ 5 - None of the above❑ UK - Unknown

Comments:______________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

ADVANCE DIRECTIVES❑ Living will ❑ Education needed❑ Do not resuscitate ❑ Copies on file❑ Organ donor ❑ Funeral arrangements made❑ POA ❑ Healthcare representative❑ State specific form(s):__________________________________________Comments:______________________________________________________

R

(M1060) Height and Weight – While measuring, if the number isX.1 – X.4 round down; X.5 or greater round up

a. Height (in inches). Record most recent height measuresince the most recent SOC/ROC

b. Weight (in pounds). Base weight on most recent measure in last 30 days; measure weight consistently,according to standard agency practice (for example, ina.m. after voiding, before meal, with shoes off, etc.)

VITAL SIGNS

inches

pounds

❑ Oral ❑ AxillaryTemperature:__________❑ Rectal ❑ Tympanic

Pulse: ❑ Apical_______ ❑ Brachial_______ ❑ Regular ❑ Irregular

❑ Radial_______ ❑ Carotid_______

Respirations:__________ ❑ Regular ❑ Irregular ❑ Cheynes Stokes❑ Death rattle ❑ Apnea periods ____sec. (❑ observed ❑ reported)❑ Accessory muscles used❑ Non-smoker ❑ Smoker Last smoked:_______________________

Blood Pressure: Left Right Sitting/Lying StandingAt rest

With activity

Post activity

Reported Weight Changes:

❑ Gain ❑ Loss __________ lb. X ______ ❑ week ❑ month ❑ year

(M1100) Patient Living Situation: Which of the following best describes the patient’s residential circumstance and availability of assistance?

Living Arrangement

a. Patient lives alone

b. Patient lives with otherperson(s) in the home

c. Patient lives in congregate situation (for example, assisted living, residential care home)

Availability of Assistance

Aroundthe clock

Regulardaytime

Regularnighttime

Occasional /short-term assistance

No assistanceavailable

Name of facility:________________________________________________________________ Phone:___________________________

❑ 01

❑ 06

❑ 11

❑ 02

❑ 07

❑ 12

❑ 03

❑ 08

❑ 13

❑ 04

❑ 09

❑ 14

❑ 05

❑ 10

❑ 15

R

LIVING ARRANGEMENTS/SUPPORTIVE ASSISTANCE

(Check one box only)


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Enter Code

(M1200) Vision (with corrective lenses if the patient usually wears them):

0 Normal vision: sees adequately in most situations; can see medication labels, newsprint.

1 Partially impaired: cannot see medication labels ornewsprint, but can see obstacles in path, and thesurrounding layout; can count fingers at arm’s length.

2 Severely impaired: cannot locate objects without hearing or touching them, or patient nonresponsive.

R

Enter Code

(M1210) Ability to Hear (with hearing aid or hearing appliance if normallyused):

0 Adequate: hears normal conversation without difficulty.

1 Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume orspeak distinctly.

2 Severely Impaired: absence of useful hearing.

UK Unable to assess hearing.

R



Patient Name______________________________________________________________________________________________________ ID #________________________________________

EARS

MOUTH

❑ No Problem❑ HOH: ❑ R ❑ L ❑ Deaf: ❑ R ❑ L ❑ Hearing aid: ❑ R ❑ L❑ Vertigo ❑ Tinnitus: ❑ R ❑ L

❑ Other (specify):________________________________________________

______________________________________________________________

______________________________________________________________

❑ No Problem❑ Dentures: ❑ Upper ❑ Lower ❑ Partial ❑ Mass(es) ❑ Tumor(s)❑ Gingivitis ❑ Ulceration(s) ❑ Toothache ❑ Lesion(s)

❑ Other (specify):________________________________________________

______________________________________________________________

______________________________________________________________


LIVING ARRANGEMENTS/SUPPORTIVE ASSISTANCE SENSORY STATUS

❑ No Problem ❑ PERRLA

❑ Pupils unequal ❑ Glasses

❑ Glaucoma: ❑ R ❑ L ❑ Cataract(s): ❑ R ❑ L

❑ Scleral icterus/yellowing ❑ Contacts: ❑ R ❑ L

❑ Blurred vision: ❑ R ❑ L ❑ Ptosis: ❑ R ❑ L

❑ Prosthesis: ❑ R ❑ L ❑ Blind: ❑ R ❑ L

❑ Other:________________________________________________________

❑ Infections:____________________________________________________

❑ Cataract surgery: (Right) Date:_____________ (Left) Date:_____________

How does the impaired vision interfere/ impact their function/safety?

(explain):________________________________________________________

________________________________________________________________

NOSE❑ No Problem

❑ Congestion ❑ Epistaxis ❑ Loss of smell ❑ Sinus problem

❑ Other (specify):________________________________________________

______________________________________________________________

______________________________________________________________

THROAT❑ No Problem

❑ Dysphagia ❑ Hoarseness ❑ Lesion(s) ❑ Sore throat

❑ Other (specify):________________________________________________

______________________________________________________________

______________________________________________________________

Primary Caregiver

Patient provides their own care: ❑ Total ❑ Partial

Reported by:__________________________________ ❑ Not reported

Does the patient feel safe providing their own care? ❑ Yes ❑ No

If no, comment:_______________________________________________

_____________________________________________________________

_____________________________________________________________

Primary caregiver(s) other than patient: ❑ None available

❑ Family member(s) ❑ Friend(s)

Paid service other than home health staff:

Company name:_________________________________________________

Phone number:___________________

Contact name:__________________________________________________

Primary Caregiver(s) Information:

Name:__________________________________________________________

Relationship:_____________________ Phone Number:_________________

Mailing address:_________________________________________________

________________________________________________________________

Email address:___________________________________________________

Name:__________________________________________________________

Relationship:_____________________ Phone Number:_________________

Mailing address:_________________________________________________

________________________________________________________________

Email address:___________________________________________________

Caregiver(s) assist with (ADLs, IADLs and/or medical cares):

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Caregiver(s) willing to assist? ❑ Yes ❑ No ❑ Unknown If no or

unknown, explain:________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Does the caregiver feel safe assisting the patient? ❑ Yes ❑ No

❑ Unknown If no or unknown, explain:_____________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

List below the hours and days a caregiver is available to provide cares. ❑ There is no set schedule for availability

AM Hours

PM Hours

Nights

Explain any available time that a caregiver might be present:

________________________________________________________________

________________________________________________________________

________________________________________________________________

SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY




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Patient Name______________________________________________________________________________________________________ ID #________________________________________



SPEECH/ORAL (VERBAL) EXPRESSION


Enter Code

Enter Code

(M1220) Understanding of Verbal Content in patient’s own language (with hearing aid or device if used):

0 Understands: clear comprehension without cues or repetitions.1 Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.2 Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.3 Rarely/Never Understands.UK Unable to assess understanding.

R

R(M1230) Speech and Oral (Verbal) Expression of Language (in patient’s own language):

0 Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.1 Minimal difficulty in expressing ideas and needs (may take extra time; makes occasional errors in word choice, grammar or speech

intelligibility; needs minimal prompting or assistance).2 Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech

intelligibility). Speaks in phrases or short sentences.3 Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener. Speech limited to single

words or short phrases.4 Unable to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (for example, speech

is nonsensical or unintelligible).5 Patient nonresponsive or unable to speak.

PAIN

Intensity: (using scales below)

0No

Pain

2 4 6 8 10Worst

Possible Pain

Wong-Baker FACES Pain Rating Scale

Collected using: ❑ FACES Scale ❑ 0-10 Scale (subjective reporting)

**From Wong D.L., Hockenberry-Eaton M., Wilson D., Winkelstein M.L., Schwartz P.: Wong’sEssentials of Pediatric Nursing, ed. 6, St. Louis, 2001, p. 1301. Copyrighted by Mosby, Inc.Reprinted by permission.

ModeratePain

NO HURT HURTSLITTLE BIT

HURTSLITTLE MORE

HURTSEVEN MORE

HURTSWHOLE LOT

HURTSWORSE

❑ No Problem Is patient experiencing pain? ❑ Yes ❑ No ❑ Unable to communicateNon-verbals demonstrated: ❑ Diaphoresis ❑ Grimacing

❑ Moaning ❑ Crying ❑ Guarding ❑ Irritability ❑ Anger ❑ Tense ❑ Restlessness ❑ Change in vital signs ❑ Other:_____________________________________________________

___________________________________________________________

Instructions: Observe the older person both at rest and during activity/with movement. For each of the items included in the PAINAD, select the score (0, 1, or 2) thatreflects the current state of the person’s behavior. Add the score for each item to achieve a total score. Monitor changes in the total score over time and in response totreatment to determine changes in pain. Higher scores suggest greater pain severity.Note: Behavior observation scores should be considered in conjunction with knowledge of existing painful conditions and report from an individual knowledgeable of theperson and their pain behaviors. Remember that some individuals may not demonstrate obvious pain behaviors or cues.*Reference: Warden, V, Hurley AC, Volicer, V. (2003). Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) Scale. J Am Med Dir Assoc, 4:9-15.Developed at the New England Document updated 1.10.2013.

Pain Assessment

Location

Onset

Present level (0-10)

Worst pain gets (0-10)

Best pain gets (0-10)

Pain description(aching, radiating,throbbing, etc.)

Site 1 Site 2 Site 3

Non-verbals demonstrated: (Cont’d)❑ Self-assessment ❑ Implications:_____________________________

_________________________________________________________________________________________________________________________________________________________________________________

How does the pain interfere/impact the patient’s safety? ❑ N/A (explain):

________________________________________________________________

________________________________________________________________

________________________________________________________________

Pain Assessment IN Advanced Dementia - PAINAD*SCORE210ITEMS

BreathingIndependent of Vocalization Normal

Occasional labored breathing.Short period of hyperventilation.

Noisy labored breathing.Long period of hyperventilation.

Cheyne-Stokes respirations.

Negative Vocalization NoneOccasional moan or groan.

Low level speech with anegative or disapproving quality.

Repeated troubled calling out.Loud moaning or groaning. Crying.

Facial Expression Smiling, or inexpressive Sad, Frightened, Frowning. Facial grimacing

Body Language Relaxed Tense, Distressed pacing, Fidgeting. Rigid. Fists clenched, Knees pulled up.Pulling or pushing away. Striking out.

Consolability No need to console Distracted or reassured by voice or touch. Unable to console, distract or reassure.

TOTAL**

Check box to indicate which pain assessment was used.❑ Wong-Baker ❑ PAINAD

**Total scores range from 0 to 10 (based on a scale of 0 to 2 for five items), with a higher score indicating more severe pain 0 = “no pain” to 10 = “severe pain”).

O


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Enter Code

(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 (for

example, mobility, incontinence, nutrition) without use ofstandardized tool

2 Yes, using a standardized, validated tool (for example,Braden Scale, Norton Scale)

Enter Code

Enter Code

(M1240) Has this patient had a formal Pain Assessment using a standardized, validated pain assessment tool (appropriate to the patient’sability to communicate the severity of pain)?

0 No standardized, validated assessment conducted1 Yes, and it does not indicate severe pain2 Yes, and it indicates severe pain

(M1242) Frequency of Pain Interfering with patient’s activity or movement:

0 Patient has no pain1 Patient has pain that does not interfere with activity or

movement2 Less often than daily3 Daily, but not constantly4 All of the time

Patient Name______________________________________________________________________________________________________ ID #________________________________________




P HH

PAIN (Cont’d) ENDOCRINE/HEMATOLOGY (Cont’d)

HH ★$ RO

What makes pain worse? ❑ Movement ❑ Ambulation ❑ Immobility

❑ Other:______________________________________________________

Is there a pattern to the pain? (explain):_____________________________

________________________________________________________________

________________________________________________________________

What makes pain better? ❑ Heat ❑ Ice ❑ Massage ❑ Repositioning

❑ Rest ❑ Relaxation ❑ Medication ❑ Diversion

❑ Other:_____________________________________________________

How often is breakthrough medication needed? ❑ Never

❑ Less than daily ❑ Daily ❑ 2-3 times/day

❑ More than 3 times/day

Does the pain radiate? ❑ Occasionally ❑ Continuously ❑ Intermittent

Current pain control medications adequate: ❑ Yes ❑ No

Comment:_______________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

ENDOCRINE/HEMATOLOGY❑ No Problem

Disorder(s) of endocrine system (type):_____________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

❑ Fatigue ❑ Intolerance to heat ❑ Intolerance to cold

Disorder(s) of blood (type)_________________________________________

❑ Anemia (specify if known)______________________________________❑ Secondary bleed: ❑ GI ❑ GU ❑ GYN ❑ Unknown ❑ Hemophilia

❑ Other:______________________________________________________

❑ Diabetes: ❑ Type 1 ❑ Type 2 Date of onset:__________________

❑ Diabetic diet ❑ Oral medication ❑ Injectable medication

❑ Medication name, dose / frequency (specify): _____________________

_____________________________________________________________

_____________________________________________________________

On medication since: __________________________________________

Administered by: ❑ Self ❑ Caregiver ❑ Nurse ❑ Family

❑ Other:_____________________________________

❑ Hyperglycemia: ❑ Glycosuria ❑ Polyuria ❑ Polydipsia

❑ Hypoglycemia: ❑ Sweats ❑ Polyphagia ❑ Weak ❑ Faint ❑ Stupor

A1C _______% ❑ Patient reported

❑ Lab slip Date:______________

BS _______mg/dL Date:______________ Time:______________

❑ FBS ❑ Before meal ❑ Postprandial ❑ Random ❑ HS

❑ Blood sugar ranges:___________________

❑ Patient ❑ Caregiver ❑ Family Report

Monitored by: ❑ Self ❑ Caregiver ❑ Family ❑ Nurse

❑ Other:________________________________________

Frequency of monitoring:_____________________________________

Competency with use of Glucometer: ___________________________

❑ Disease Management Problems (explain): _____________________________________________________________

_____________________________________________________________

_____________________________________________________________

INTEGUMENTARY STATUS❑ No Problem

Disorder(s) of skin, hair, nails (details): ______________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Check all applicable conditions listed below:

Turgor: ❑ Good ❑ Poor

❑ Itch ❑ Rash ❑ Dry ❑ Scaling ❑ Redness ❑ Bruises

❑ Ecchymosis ❑ Pallor ❑ Jaundice

❑ Other (specify):________________________________________________

________________________________________________________________

Definitions:

• Unhealed: The absence of the skin’s original integrity.

• Non-epithelialized: The absence of the regeneration of the epidermisacross a wound surface.

• Pressure Ulcer: A pressure ulcer is localized injury to the skin and/orunderlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear. A number of contributing or confounding factors also are associated with pressureulcers; the significance of these factors is yet to be elucidated.

P

PA

R

R

R

HH

Enter Code

(M1302) Does this patient have a Risk of Developing Pressure Ulcers?

0 No

1 Yes

Enter Code

(M1306) Does this patient have at least one Unhealed Pressure Ulcer atStage 2 or Higher or designated as Unstageable? (Excludes Stage 1pressure ulcers and healed Stage 2 pressure ulcers)

0 No [Go to M1322]

1 Yes

Complete Braden Scale form per organizational guideline (Briggs#3166). OASIS Scoring Instructions (see page 10 of 27).


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Patient Name______________________________________________________________________________________________________ ID #________________________________________




Enter Code

(M1330) Does this patient have a Stasis Ulcer?

0 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/device)[Go to M1340]

$ R

Enter Code

(M1332) Current Number of Stasis Ulcer(s) that are Observable:

1 One 3 Three2 Two 4 Four or more

$ R

Enter Code

(M1334) Status of Most Problematic Stasis Ulcer that is Observable:

1 Fully granulating 3 Not healing2 Early/partial granulation

Enter Code

(M1340) Does this patient have a Surgical Wound?

0 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/device [Go to M1350]

Enter Code

(M1342) Status of Most Problematic Surgical Wound that is Observable

0 Newly epithelialized1 Fully granulating2 Early/partial granulation3 Not healing

Enter Code

(M1350) Does this patient have a Skin Lesion or Open Wound (excluding bowel ostomy), other than those described above, that isreceiving intervention by the home health agency?

0 No1 Yes

Enter Code

(M1324) Stage of Most Problematic Unhealed Pressure Ulcer that isStageable: (Excludes pressure ulcer that cannot be staged due to anon- removable dressing/device, coverage of wound bed by slough and/or eschar, or suspected deep tissue injury.)

1 Stage 1

2 Stage 2

3 Stage 3

4 Stage 4

NA Patient has no pressure ulcers or no stageable pressureulcers

PA$ R

Enter Code

Enter Code

(M1320) Status of Most Problematic Pressure Ulcer that isObservable: (Excludes pressure ulcer that cannot be observed due to anon-removable dressing/device)

0 Newly epithelialized

1 Fully granulating

2 Early/partial granulation

3 Not healing

NA No observable pressure ulcer

(M1322) Current Number of Stage 1 Pressure Ulcers: Intact skin withnon-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler ascompared to adjacent tissue. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistentblue or purple hues.

0

1

2

3

4 or more

INTEGUMENTARY STATUS (Cont’d)

$ R

• Early/partial granulation:• ≥25% of the wound bed is covered with granulation tissue.• <25% of the wound bed is covered with avascular tissue (eschar

and/or slough).• No signs or symptoms of infection.• Wound edges open.

• Not healing:• Wound with ≥25% avascular tissue (eschar and/or slough) OR• Signs/symptoms of infection OR• Clean but non-granulating wound bed OR• Closed/hyperkeratotic wound edges OR• Persistent failure to improve despite appropriate comprehensive

wound management.

Definitions:• Newly epithelialized:

• Wound bed completely covered with new epithelium.• No exudate.• No avascular tissue (eschar and/or slough).• No signs or symptoms of infection.

• Fully granulating:• Wound bed filled with granulation tissue to the level of the

surrounding skin.• No dead space.• No avascular tissue (eschar and/or slough).• No signs or symptoms of infection.• Wound edges are open.

EnterNumber(M1311) Current Number of Unhealed Pressure Ulcers at Each Stage

A1. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May alsopresent as an intact or open/ruptured blister.Number of Stage 2 pressure ulcers

B1. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may bepresent but does not obscure the depth of tissue loss. May include undermining and tunneling.Number of Stage 3 pressure ulcers

C1. Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the woundbed. Often includes undermining and tunneling.Number of Stage 4 pressure ulcers

D1. Unstageable: Non-removable dressing: Known but not stageable due to non-removable dressing/device. Number of unstageable pressure ulcers due to non-removable dressing/device

E1. Unstageable: Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar.Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar

F1. Unstageable: Deep tissue injury: Suspected deep tissue injury in evolution.Number of unstageable pressure ulcers with suspected deep tissue injury in evolution

PA$ R

HHRO

PAHH$ RO

R

PA$ R


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INTEGUMENTARY STATUS (Cont’d)Patient Name______________________________________________________________________________________________________ ID #________________________________________


OASIS SCORING INSTRUCTIONS:• Home health agencies may adopt the NPUAP guidelines in their clinical practice and documentation. However, since CMS has adapted the

NPUAP guidelines for OASIS purposes, the definitions do not perfectly align with each stage as described by NPUAP. When discrepancies existbetween the NPUAP definitions and the OASIS scoring instructions provided in the OASIS Guidance Manual and CMS Q&As, providersshould rely on the CMS OASIS instructions.

• Pressure ulcers are defined as localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.

• If pressure is not the primary cause of the lesion, do not report the wound as a pressure ulcer.• Terminology referring to “healed” vs. “unhealed” ulcers can refer to whether the ulcer is “closed” vs. “open”. Recognize, however, that Stage 1

pressure ulcers and Suspected Deep Tissue Injury (sDTI), although closed (intact skin), would not be considered healed. Unstageable pressureulcers, whether covered with a non-removable dressing or eschar or slough, would not be considered healed.

• Stage 2 (partial thickness) pressure ulcers heal through the process of regeneration of the epidermis across a wound surface, known as “re-epithe-lialization.”

• Stage 3 and 4 (full thickness) pressure ulcers heal through a process of granulation (filling of the wound with connective/scar tissue), contraction(wound margins contract and pull together), and re-epithelialization (covers with epithelial tissue from within wound bed and/or from wound margins). Once the pressure ulcer has fully granulated and the wound surface is completely covered with new epithelial tissue, the wound is considered closed, and will continue to remodel and increase in tensile strength. For the purposes of scoring the OASIS, the wound is considered healed at this point, and should no longer be reported as an unhealed pressure ulcer.

• Agencies should be aware that the patient is at higher risk of having the site of a closed pressure ulcer open up due to damage, injury, or pressure,because of the loss of tensile strength of the overlying tissue. Tensile strength of the skin overlying a closed full thickness pressure ulcer is only80% of normal skin tensile strength. Agencies should pay careful attention that preventative measures are put into place that will mitigate the re-opening of a closed ulcer.

• Do not reverse stage pressure ulcers as a way to document healing as it does not accurately characterize what is physiologically occurring as theulcer heals.

DEFINITIONS – Pressure Ulcer/Injury Stages:

Stage 1 ulcers• Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler

as compared to adjacent tissue. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blueor purple hues.

Stage 2 ulcers• Definition: Stage 2 pressure ulcers are characterized by partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound

bed, without slough. May also present as an intact or open/ruptured blister.Stage 3 and 4 ulcers• Definition: Stage 3 pressure ulcers are characterized by full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is

not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling.• Definition: Stage 4 pressure ulcers are characterized by full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be

present on some parts of the wound bed. Often includes undermining and tunneling.Additional Information• Report the number of Stage 2 or higher pressure ulcers that are present on the current day of assessment.• If any bone, tendon or muscle or joint capsule (Stage 4 structures) is visible, the pressure ulcer should be reported as a Stage 4 pressure ulcer,

regardless of the presence or absence of slough and/or eschar in the wound bed.• A previously closed Stage 3 or Stage 4 pressure ulcer that is currently open again should be reported at its worst stage.• If the patient has been in an inpatient setting for some time, it is conceivable that the wound has already started to granulate, thus making it

challenging to know the stage of the wound at its worst. The clinician should make every effort to contact previous providers (including patient’sphysician) to determine the stage of the wound at its worst. An ulcer's stage can worsen, and this item should be answered using the worst stageif this occurs.

• A muscle flap, skin advancement flap, or rotational flap (defined as full thickness skin and subcutaneous tissue partially attached to the body bya narrow strip of tissue so that it retains its blood supply) performed to surgically replace a pressure ulcer is a surgical wound. It should not bereported as a pressure ulcer on M1311.

• A pressure ulcer treated with a skin graft (defined as transplantation of skin to another site) should not be reported as a pressure ulcer and untilthe graft edges completely heal, should be reported as a surgical wound on M1340.

• A pressure ulcer that has been surgically debrided remains a pressure ulcer and should not be reported as a surgical wound on M1340.Unstageable ulcers• Definition: Pressure ulcers covered with slough and/or eschar are unstageable. Rationale: The true anatomic depth of soft tissue damage (and

therefore stage) cannot be determined. The pressure ulcer stage can be determined only when enough slough and/or eschar is removed to exposethe anatomic depth of soft tissue damage.

• Pressure ulcers that are known to be present but that are Unstageable due to a dressing/device, such as a cast that cannot be removed to assessthe skin underneath, should be reported as unstageable. “Known” refers to when documentation is available that states a pressure ulcer existsunder the non-removable dressing/device. Examples of a non-removable dressing/device include a dressing that is not to be removed per physician’s order (such as those used in negative-pressure wound therapy [NPWT], an orthopedic device, or a cast.

• Suspected deep tissue injury in evolution, which is defined as a purple or maroon localized area of discolored intact skin or blood-filled blister dueto damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer,or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include athin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additionallayers of tissue even with optimal treatment.


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Location

Type

Size (cm) (LxWxD)

Tunneling /Sinus Tract

Undermining (cm)

Stage (pressure ulcers only)

Date Healed

Odor

Surrounding Skin

Edema

Appearance ofthe Wound Bed

Drainage/Amount

Color

Consistency

WOUND/LESIONDate Originally Reported ➤

❑ None❑ Small❑ Moderate❑ Large

❑ Clear❑ Tan❑ Serosanguineous❑ Other

❑ Thin❑ Thick



❑ Thin❑ Thick



❑ Thin❑ Thick



❑ Thin❑ Thick



❑ Thin❑ Thick

length______cm@ _____o’clock

______cm, from_____ to _____ o’clock


______cm, from_____ to _____ o’clock


______cm, from_____ to _____ o’clock


______cm, from_____ to _____ o’clock


______cm, from_____ to _____ o’clock

Patient Name______________________________________________________________________________________________________ ID #________________________________________



INTEGUMENTARY STATUS (Cont’d)

BRIGGS INTEGUMENTARY STATUS CHART


WOUND CARE: (Check all that apply) ❑ N/A

Wound care done during this visit: ❑ Yes ❑ No Location(s) wound site:________________________________________________________________

❑ Soiled dressing removed by:

❑ Patient ❑ Caregiver (name)______________________________________ ❑ Family ❑ RN ❑ PT ❑ Other:_______________________________

Technique: ❑ Sterile ❑ Clean

❑ Wound cleaned with (specify):_____________________________________________________________________________________________________

❑ Wound irrigated with (specify):______________________________________________________________________________________________________

❑ Wound packed with (specify):______________________________________________________________________________________________________

❑ Wound dressing applied (specify):___________________________________________________________________________________________________

Patient tolerated procedure well: ❑ Yes ❑ No

Comments:_________________________________________________________________________________________________________________________

DIABETIC FOOT EXAM: (Check all that apply) ❑ N/A

Frequency of diabetic foot exam_____________________________________________________________________________________________________

Done by: ❑ Patient ❑ Caregiver (name)___________________________________ ❑ Family ❑ RN ❑ PT ❑ Other:__________________________

Exam by clinician this visit: ❑ Yes ❑ No

Integument findings:________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

Pedal pulses: Present ❑ right ❑ left Absent ❑ right ❑ left Comment:________________________________________________________________

Loss of sense of: Warm ❑ right ❑ left Cold ❑ right ❑ left Comment:________________________________________________________________

Neuropathy ❑ right ❑ left Tingling ❑ right ❑ left Burning ❑ right ❑ left Leg hair: Present ❑ right ❑ left Absent ❑ right ❑ left

Complete LEAP Diabetic Foot Screening (Briggs form 3484P) per organizational guideline

Comments:_________________________________________________________________________________________________________________________

❑ Arterial❑ Diabetic foot ulcer❑ Malignancy❑ Mechanical/Trauma❑ Pressure ulcer❑ Surgical❑ Venous stasis ulcer





#1 _____________ #2 _____________ #3 _____________ #4 _____________ #5 _____________


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CARDIOPULMONARY RESPIRATORY STATUS (Cont’d)Patient Name______________________________________________________________________________________________________ ID #________________________________________

Disorder(s) of heart/respiratory system (type): _______________________________________________________________________________________________________________________________________________________________________________________________________________________

Breath Sounds:(e.g., clear, crackles/rales, wheezes/rhonchi, diminished, absent)

Anterior:Right________________________ Left ____________________________Posterior:Right Upper_________________ Left Upper_______________________Right Lower_________________ Left Lower_______________________

O2 @ _____ LPM via ❑ cannula ❑ mask ❑ trach O2 saturation _____%Trach size/ type___________________________________________________

Who manages? ❑ Self ❑ RN ❑ Caregiver ❑ Family______________________________________________________________

Intermittent treatments (e.g., C&DB, medicated inhalation treatments, etc.)❑ No❑ Yes, explain:_________________________________________________

________________________________________________________________________________________________________________________

❑ Cough: ❑ No❑ Yes: ❑ Productive ❑ Non-productiveDescribe:______________________________________________

Positioning necessary for improved breathing:❑ No ❑ Yes, describe:_______________________________________________________________________________________________________

Heart Sounds: ❑ Regular ❑ Irregular ❑ Murmur❑ Pacemaker: Date:_____________ Last date checked:______________

Type:___________________________________________❑ Chest Pain: ❑ Anginal ❑ Postural ❑ Localized ❑ Substernal

❑ Radiating ❑ Dull ❑ Ache ❑ Sharp ❑ Vise-likeAssociated with: ❑ Shortness of breath ❑ Activity ❑ SweatsFrequency/duration:____________________________________________How relieved:________________________________________________________________________________________________________________❑ Palpitations ❑ Fatigue

❑ Edema: ❑ Pedal ❑ Right ❑ Left ❑ Sacral ❑ Dependent:__________________________________________

❑ Pitting ❑ +1 ❑ +2 ❑ +3 ❑ +4 ❑ Non-pitting Site:___________________________________________________________

❑ Cramps ❑ Claudication Capillary refill: ❑ Less than 3 seconds ❑ Greater than 3 seconds❑ Disease Management Problems (explain): _______________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

(M1410) Respiratory Treatments utilized at home: (Mark all that apply.)❑ 1 - Oxygen (intermittent or continuous)❑ 2 - Ventilator (continually or at night)❑ 3 - Continuous / Bi-level positive airway pressure❑ 4 - None of the above


RESPIRATORY STATUS

HH ★$ ROEnter Code

(M1400) When is the patient dyspneic or noticeably Short of Breath?

0 Patient is not short of breath1 When walking more than 20 feet, climbing stairs2 With moderate exertion (for example, while dressing, using

commode or bedpan, walking distances less than 20 feet)3 With minimal exertion (for example, while eating, talking, or

performing other ADLs) or with agitation4 At rest (during day or night)

R

NUTRITIONAL STATUS❑ No Problem

❑ NAS ❑ NPO ❑ Controlled Carbohydrate ❑ Other:________________

Nutritional requirements (diet)

________________________________________________________________

❑ Increase fluids:____________amt. ❑ Restrict fluids:____________amt.

Appetite: ❑ Good ❑ Fair ❑ Poor ❑ Anorexic ❑ Nausea❑ Vomiting: Frequency:_________________ Amount:___________________❑ Heartburn (food intolerance) ❑ Other:_____________________________Nutritional Approaches: Check all that apply❑ Parenteral/IV feeding ❑ Feeding tube – nasogastric or abdominal (e.g. PEG, NG)❑ Mechanically altered diet – change of texture with solids or fluids

(e.g., pureed or thickened)❑ Therapeutic diet – (e.g., low salt, low cholesterol, gluten free, diabetic)❑ N/A

Directions: Check each area with “yes” to assessment, then total scoreto determine additional risk. YESHas an illness or condition that changed the kind and/or amount of food eaten. ❑ 2Eats 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 and/or feed self. ❑ 2

TOTALReprinted 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 OF ASSESSMENT

0-2 Good. As appropriate reassess and/or provide information based on situation.3-5 Moderate risk. Educate, refer, monitor and reevaluate based on patient situationand organization policy.6 or more High risk. Coordinate with physician, dietitian, social service profes sionalor nurse about how to improve nutritional health. Reassess nutritional status and educate based on plan of care.

Describe at risk intervention and plan:______________________________________________________________________________________________

ENTERAL FEEDINGS - ACCESS DEVICE❑ N/A ❑ No Problem

❑ Nasogastric ❑ Gastrostomy ❑ Jejunostomy❑ Other (specify):__________________________________________________❑ Pump: (type/specify):____________________________________________

❑ Bolus ❑ ContinuousFeedings: Type (amt. /rate): _________________________________________Flush Protocol: (amt./specify):_______________________________________Performed by: ❑ Self ❑ RN ❑ Caregiver ❑ Family

❑ Other:____________________________________________Dressing/Site care: (specify):__________________________________________________________________________________________________________Interventions /Instructions/Comments:___________________________________________________________________________________________________________________________________________________________________❑ Assessed ❑ Reported


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Enter Code

(M1620) Bowel Incontinence Frequency:

0 Very rarely or never has bowel incontinence1 Less than once weekly2 One to three times weekly3 Four to six times weekly4 On a daily basis5 More often than once dailyNA Patient has ostomy for bowel eliminationUK Unknown

Enter Code

(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?

0 Patient does not have an ostomy for bowel elimination.1 Patient’s ostomy was not related to an inpatient stay and

did not necessitate change in medical or treatmentregimen.

2 The ostomy was related to an inpatient stay or did neces-sitate change in medical or treatment regimen.

O $ R

$

ABDOMEN

GENITALIA

❑ No Problem❑ Tenderness ❑ Pain ❑ Distention ❑ Hard ❑ Soft ❑ Ascites❑ Abdominal girth ________ cm❑ Other:________________________________________________________

❑ No Problem❑ Discharge/Drainage: (describe):__________________________________❑ Lesions ❑ Blisters ❑ Masses ❑ Cysts❑ Inflammation ❑ Surgical alteration❑ Prostate problem: ❑ BPH ❑ TURP Date:_____________❑ Self-testicular exam Freq._______ Date last exam:_____________❑ Menopause ❑ Hysterectomy Date:_____________Date last PAP:_____________ Results:____________________________❑ Breast self-exam Freq._______ Date last exam:______________

❑ Nipple discharge: ❑ R Date:_____________ ❑ L Date:_____________❑ Mastectomy: ❑ R Date:_____________ ❑ L Date:_____________❑ Other (specify):________________________________________________

Enter Code

(M1600) Has this patient been treated for a Urinary Tract Infection inthe past 14 days?

0 No1 YesNA Patient on prophylactic treatmentUK Unknown



ELIMINATION STATUS ELIMINATION STATUS (Cont’d)Patient Name______________________________________________________________________________________________________ ID #________________________________________


Urinary Elimination: ❑ No ProblemDisorder(s) of urinary system (type):________________________________________________________________________________________________

(Check all applicable items)

❑ Urgency ❑ Frequency ❑ Retention ❑ Burning ❑ Pain

❑ Hesitancy ❑ Nocturia ❑ Hematuria ❑ Oliguria ❑ Anuria

❑ Incontinence (details if applicable): _____________________________________________________________________________________________________________________________________________________________________________________________________________

Color: ❑ Yellow/straw ❑ Amber ❑ Brown/gray ❑ Blood-tinged

❑ Other:____________________________

Clarity: ❑ Clear ❑ Cloudy ❑ Sediment ❑ Mucous

Odor: ❑ Yes ❑ No ❑ Observed ❑ Reported

❑ Incontinence products/other:____________________________________

Urinary Catheter: Type:_____________ Date last changed:____________

❑ Foley inserted (date)________________ with _____________ French

Inflated balloon with ______mL ❑ without difficulty ❑ Suprapubic

Irrigation solution: Type (specify): ________________________________

Amount_____mL Frequency_____________ Returns ______________Patient tolerated procedure well ❑ Yes ❑ No

❑ Urostomy site (describe skin around stoma):____________________________________________________________________________________

______________________________________________________________

Ostomy care managed by: ❑ Self ❑ Caregiver ❑ Family

❑ Disease Management Problems (explain): _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PAO

Enter Code

(M1610) Urinary Incontinence or Urinary Catheter Presence:

0 No incontinence or catheter (includes anuria or ostomy forurinary drainage) [Go to M1620]

1 Patient is incontinent2 Patient requires a urinary catheter (specifically: external,

indwelling, intermittent, or suprapubic) [Go to M1620]

Enter Code

(M1615) When does Urinary Incontinence occur?

0 Timed-voiding defers incontinence1 Occasional stress incontinence2 During the night only3 During the day only4 During the day and night

O $ R

O R

Bowel Elimination: ❑ No Problem

Disorder(s) of GI system (type)_____________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

❑ Flatulence ❑ Constipation ❑ Fecal impaction ❑ Diarrhea

❑ Rectal bleeding ❑ Hemorrhoids ❑ Last BM: _________________

RU LU

RL LL

❑ Bowel sounds: active________________________

absent_______________________

hypoactive___________________

hyperactive___________________

❑ Frequency of stools______________________

Bowel regimen/program:________________________________________

❑ Laxative ❑ Enema use: ❑ Daily ❑ Weekly ❑ Monthly ❑ PRN

❑ Other: ______________________________________________________

❑ Involuntary incontinence (details if applicable):____________________

_____________________________________________________________

_____________________________________________________________

❑ Incontinence products/other:____________________________________

❑ Ileostomy ❑ Colostomy site (describe skin around stoma): _________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

Ostomy care managed by: ❑ Self ❑ Caregiver ❑ Family

❑ Other: ________________________________________________________

_____________________________________________________________

_____________________________________________________________


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Enter Code

(M1730) Depression Screening: Has the patient been screened for depression, using a standardized, validated depression screening tool?

0 No

1 Yes, patient was screened using the PHQ-2©* scale.

PHQ-2©* Not at all0 - 1 day

Several days2 - 6 days

More than halfof the days7 - 11 days

Nearlyevery day

12 - 14 days

NAUnable torespond

a) Little interest or pleasure in doing things

b) Feeling down, depressed, or hopeless?

❑ 0

❑ 0

❑ 1

❑ 1

❑ 2

❑ 2

❑ 3

❑ 3

❑ NA

❑ NA

P R HH

*Copyright© Pfizer Inc. All rights reserved. Reproduced with permission.

2 Yes, patient was screened with a different standardized, validated assessment and the patient meets criteria for further evaluation for depression.

3 Yes, patient was screened with a different standardized, validated assessment and the patient does not meet criteria for furtherevaluation for depression.

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?”

(M1740) Cognitive, behavioral, and psychiatric symptoms that are demonstrated at least once a week (Reported or Observed): (Mark all thatapply.)

❑ 1 - Memory deficit: failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required

❑ 2 - Impaired decision-making: failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions

❑ 3 - Verbal disruption: yelling, threatening, excessive profanity, sexual references, etc.

❑ 4 - Physical aggression: aggressive or combative to self and others (for example, hits self, throws objects, punches, dangerous maneuvers with wheelchair or other objects)

❑ 5 - Disruptive, infantile, or socially inappropriate behavior (excludes verbal actions)

❑ 6 - Delusional, hallucinatory, or paranoid behavior

❑ 7 - None of the above behaviors demonstrated

PAR

Enter Code

(M1710) When Confused (Reported or Observed Within the Last 14Days):

0 Never1 In new or complex situations only2 On awakening or at night only3 During the day and evening, but not constantly4 ConstantlyNA Patient nonresponsive



NEURO/EMOTIONAL / BEHAVIORAL STATUSPatient Name______________________________________________________________________________________________________ ID #________________________________________

❑ No ProblemDisorder(s) of neurological system (type):___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________❑ History of a traumatic brain injury Date:_____________❑ History of headaches Date of last headache:_____________

(Type):______________________________________________________________________________________________________________________

❑ Aphasic: ❑ Receptive ❑ Expressive❑ Tremors: ❑ At Rest ❑ With voluntary movement ❑ Continuous❑ Spasms (for example; back, bladder, legs) Location:_______________

____________________________________________________________________________________________________________________________

❑ History of seizures Date of last:_____________(Type):______________________________________________________________________________________________________________________

❑ Hemiplegia: ❑ Right ❑ Left❑ Paraplegia ❑ Quadriplegia ❑ TetraplegiaHow does the patient’s condition affect functional ability and safety?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Enter Code

(M1700) Cognitive Functioning: Patient’s current (day of assessment)level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.

0 Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.

1 Requires prompting (cuing, repetition, reminders) onlyunder stressful or unfamiliar conditions.

2 Requires assistance and some direction in specific situations (for example, on all tasks involving shifting ofattention) or consistently requires low stimulus environmentdue to distractibility.

3 Requires considerable assistance in routine situations. Isnot alert and oriented or is unable to shift attention andrecall directions more than half the time.

4 Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.

PO R HH

PAPO R HH

Enter Code

(M1720) When Anxious (Reported or Observed Within the Last 14Days):

0 None of the time1 Less often than daily2 Daily, but not constantly3 All of the timeNA Patient nonresponsive

PO R HH


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ROEnter Code

(M1745) Frequency of Disruptive Behavior Symptoms (Reported orObserved): Any physical, verbal, or other disruptive /dangerous symptoms that are injurious to self or others or jeopardize personal safety.

0 Never1 Less than once a month2 Once a month3 Several times each month4 Several times a week5 At least daily

Enter Code

(M1750) Is this patient receiving Psychiatric Nursing Services at homeprovided by a qualified psychiatric nurse?

0 No1 Yes



NEURO/EMOTIONAL / BEHAVIORAL STATUS (Cont’d) PSYCHOSOCIAL (Cont’d)Patient Name______________________________________________________________________________________________________ ID #________________________________________

Primary language:______________________________________________❑ Language barrier ❑ Needs interpreter

❑ Sign language (type):___________________________________________

❑ Learning barrier: ❑ Mental ❑ Psychosocial ❑ Physical ❑ Functional

❑ Unable to: ❑ Read ❑ Write Educational level:_____________________

❑ Spiritual ❑ Cultural implications that impact care

Explain:______________________________________________________

________________________________________________________________

Spiritual resource: _______________________________________________

Phone No.______________________________________________________

Marital status: ❑ Single ❑ Married ❑ Divorced ❑ Widower

Number of children _____ Ages and gender:_________________________

_________________________________________________________________

Do children live near the patient? ❑ Yes ❑ No

❑ No Problem

Disorder(s) of musculoskeletal system (type):________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

❑ Fracture (location):_____________________________________________

❑ Swollen, painful joints (specify): _________________________________

❑ Contracture(s) Location:________________________________________

Hand grips: ❑ Equal ❑ Unequal ❑ Strong ❑ Weak (specify):________

______________________________________________________________

______________________________________________________________

Dominant side: ❑ R ❑ L

❑ Motor changes: ❑ Fine ❑ Gross (specify):_______________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

❑ Weakness: ❑ UE ❑ LE (details):________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

❑ Atrophy_________________ ❑ Poor conditioning

❑ Decreased ROM__________ ❑ Paresthesia_______________________

❑ Shuffling ❑ Wide-based gait

PSYCHOSOCIAL

MENTAL STATUS

MUSCULOSKELETAL


Describe the patient’s mental status. Description should include theirgeneral appearance, behaviors, emotional responses, mental functioningand their overall social interaction. Include both the clinical objectiveobservations and subjective descriptions reported during this visit.Consider including information collected by items M1700-1750 andM2102 in your description.

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

Has there been a sudden/acute change in their mental status?❑ No ❑ Yes

If yes, did the change coincide with something else? For example, amedication change, a fall, the loss of a loved one or a change in their living arrangements etc. ❑ No ❑ Yes If yes, explain:_______________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

Mental status changes reported by ❑ Patient ❑ Caregiver ❑ Representative ❑ Other:________________________________________

Note: CMS is looking for potential issues that may complicate or interferewith the delivery of the HHA services and the patient’s ability to participatein his or her own care. Consider the Brief Interview For Mental Status(BIMS) for further assessment.

Consider the Confusion Assessment Method (CAM) for further cognitiveassessment

Did the patient drive a vehicle before this admission? ❑ Yes ❑ No ❑ Patient does not have a vehicle

If yes, do they want to drive again post-discharge? ❑ Yes ❑ No ❑ Unknown

Did the patient have job before this admission? ❑ Yes ❑ No If yes, do they want to return to work post-discharge? ❑ Yes ❑ No

❑ UnknownSleep: ❑ Adequate ❑ Inadequate Rest: ❑ Adequate ❑ Inadequate

Frequency of naps:____________________________________________

Number of hours slept per night:_____________

Explain:______________________________________________________

Feelings/emotions the patient reports when asked:❑ Angry ❑ Fear ❑ Sadness ❑ Discouraged ❑ Lonely ❑ Depressed❑ Helpless ❑ Content ❑ Happy ❑ Hopeful ❑ Motivated

❑ Other:_________________________________ ❑ N/A - No answer given❑ Inability to cope with altered health status as evidenced by:

❑ Lack of motivation ❑ Inability to recognize problems❑ Unrealistic expectations ❑ Denial of problems

Evidence of: ❑ Abuse ❑ Neglect ❑ Exploitation; ❑ Potential ❑ Actual ❑ Verbal ❑ Emotional ❑ Physical ❑ FinancialMSW referral made: ❑ Yes ❑ No

Other intervention:_______________________________________________

Comments:________________________________________________________

__________________________________________________________________

__________________________________________________________________Note: CMS is looking for potential issues that may complicate or interferewith the delivery of the HHA services and the patient’s ability to participate in his or her own care. A psychosocial evaluation includes thepatient’s mental health, social status, and functional capacity within thecommunity by looking at issues surrounding both a patient’s psycholog-ical and social condition (for example, education and marital history).wwwwww..BBrriiggggssCCoorrpp..ccoomm

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543210

MANUAL MUSCLE TEST (MMT) MUSCLE STRENGTH

Right Left Right LeftROMSTRENGTH

AREA ACTION

Flex/Extend

Abd./Add.

Int. Rot./Ext. Rot.

Flex/Extend

Sup./Pron.

Flex/Extend

Flex/Extend

Flex/Extend

Abd./Add.

Int. Rot./Ext. Rot.

Flex/Extend

Plant./Dors.

Inver./Ever.

Shoulder

Elbow

Forearm

Wrist

Fingers

Hip

Knee

Ankle

Foot

LOW

ER E

XTRE

M.

UPPE

R EX

TREM

.

Normal functional strength - against gravity - full resistanceGood strength - against gravity with some resistanceFair strength - against gravity - no resistance - safety compromisePoor strength - unable to move against gravityTrace strength - slight muscle contraction - no motionZero - no active muscle contraction

DESCRIPTIONGRADE

ROMSTRENGTH

SPIN

E AREA ACTION

Active Passive Active Passive

REQUIRED CORE ELEMENTSAssess one point for each core element “yes”.

Information may be gathered from medical record, assessment and ifapplicable, the patient/caregiver. Beyond protocols listed below, scoring

should be based on your clinical judgment.

Points

Age 65+

Diagnosis (3 or more co-existing)Includes only documented medical diagnosis.

Prior history of falls within 3 monthsA unintentional change in position resulting in coming to rest on theground or at a lower level.

IncontinenceInability to make it to the bathroom or commode in timely manner.Includes frequency, urgency, and/or nocturia.

Visual impairmentIncludes but not limited to, macular degeneration, diabetic retinopathies,visual field loss, age related changes, decline in visual acuity, accommodation, glare tolerance, depth perception, and night vision ornot wearing prescribed glasses or having the correct prescription.

Impaired functional mobilityMay include patients who need help with IADLs or ADLs or have gait ortransfer problems, arthritis, pain, fear of falling, foot problems, impairedsensation, impaired coordination or improper use of assistive devices.

Environmental hazardsMay include but not limited to, poor illumination, equipment tubing, inappropriate footwear, pets, hard to reach items, floor surfaces that areuneven or cluttered, or outdoor entry and exits.

Poly Pharmacy (4 or more prescriptions – any type)All PRESCRIPTIONS including prescriptions for OTC meds. Drugs highlyassociated with fall risk include but not limited to, sedatives, anti- depressants, tranquilizers, narcotics, antihypertensives, cardiac meds,corticosteroids, anti-anxiety drugs, anticholinergic drugs, and hypoglycemic drugs.

Pain affecting level of functionPain often affects an individual’s desire or ability to move or pain can bea factor in depression or compliance with safety recommendations.

Cognitive impairmentCould include patients with dementia, Alzheimer’s or stroke patients orpatients who are confused, use poor judgment, have decreased comprehension, impulsivity, memory deficits. Consider patient’s ability toadhere to the plan of care.

A score of 4 or more is considered at risk for falling TOTAL

MAHC 10 reprinted with permission from Missouri Alliance for HOME CARE

MAHC 10 - FALL RISK ASSESSMENT TOOL

❑ Amputation ❑ Bowel/Bladder (Incontinence)❑ Contracture❑ Hearing❑ Paralysis❑ Endurance❑ Ambulation❑ Speech❑ Legally blind❑ Dyspnea with minimal exertion

❑ Other (specify):__________________________________________________

________________________________________________________________

________________________________________________________________

❑ Other (specify):__________________________________________________

________________________________________________________________

________________________________________________________________

Enter Code

(M1910) Has this patient had a multi-factor Falls Risk Assessmentusing a standardized, validated assessment tool?

0 No1 Yes, and it does not indicate a risk for falls2 Yes, and it does indicate a risk for falls



Patient Name______________________________________________________________________________________________________ ID #________________________________________

Plan/Comments: _________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

FALL RISK ASSESSMENTMUSCULOSKELETAL (Cont’d)


P R HH

FUNCTIONAL LIMITATIONS

MUSCLE STRENGTH/ROM EVAL

❑ Amputation: ❑ BK ❑ AK ❑ UE; ❑ R ❑ L (specify): ________________

______________________________________________________________

❑ Other (specify):________________________________________________

How does the patient’s condition affect their functional ability and safety?

(explain):________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________


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Enter Code

(M1850) Transferring: Current ability to move safely from bed to chair,or ability to turn and position self in bed if patient is bedfast.

0 Able to independently transfer.1 Able to transfer with minimal human assistance or with use

of an assistive device.2 Able to bear weight and pivot during the transfer process

but unable to transfer self.3 Unable to transfer self and is unable to bear weight or pivot

when transferred by another person.4 Bedfast, unable to transfer but is able to turn and position

self in bed.5 Bedfast, unable to transfer and is unable to turn and

position self.

HH ★PAO R$

Enter Code

(M1845) Toileting Hygiene: Current ability to maintain perineal hygienesafely, adjust clothes and/or incontinence pads before and after usingtoilet, commode, bedpan, urinal. If managing ostomy, includes cleaningarea around stoma, but not managing equipment.

0 Able to manage toileting hygiene and clothing manage-ment without assistance.

1 Able to manage toileting hygiene and clothing manage-ment without assistance if supplies/implements are laid outfor the patient.

2 Someone must help the patient to maintain toiletinghygiene and/or adjust clothing.

3 Patient depends entirely upon another person to maintaintoileting hygiene.

PAO R



Patient Name______________________________________________________________________________________________________ ID #________________________________________

ADL/IADLs


HH

PA

★PA

O $ R

O R

O $ R

PAO $ R

Enter Code

Enter Code

Enter Code

(M1800) Grooming: Current ability to tend safely to personal hygieneneeds (specifically: washing face and hands, hair care, shaving or makeup, teeth or denture care, or fingernail care).

0 Able to groom self unaided, with or without the use ofassistive devices or adapted methods.

1 Grooming utensils must be placed within reach before ableto complete grooming activities.

2 Someone must assist the patient to groom self.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:

0 Able to get clothes out of closets and drawers, put them onand remove them from the upper body without assistance.

1 Able to dress upper body without assistance if clothing islaid out or handed to the patient.

2 Someone must help the patient put on upper body clothing.3 Patient depends entirely upon another person to dress the

upper body.

(M1820) Current Ability to Dress Lower Body safely (with or withoutdressing aids) including undergarments, slacks, socks or nylons,shoes:

0 Able to obtain, put on, and remove clothing and shoeswithout assistance.

1 Able to dress lower body without assistance if clothing andshoes are laid out or handed to the patient.

2 Someone must help the patient put on undergarments,slacks, socks or nylons, and shoes.

3 Patient depends entirely upon another person to dresslower body.

O $ R

(M1830) Bathing: Current ability to wash entire body safely. Excludesgrooming (washing face, washing hands, and shampooing hair).

0 Able to bathe self in shower or tubindependently, including getting in and out of tub/shower.

1 With the use of devices, is able to bathe self in shower ortub independently, including getting in and out of thetub/shower.

2 Able to bathe in shower or tub with the intermittentassistance of another 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, butrequires presence of another person throughout the bathfor assistance or supervision.

4 Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at thesink, in chair, or on commode.

5 Unable to use the shower or tub, but able to participate inbathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of anotherperson.

6 Unable to participate effectively in bathing and is bathedtotally by another person.

Enter Code

(M1840) Toilet Transferring: Current ability to get to and from the toiletor bedside commode safely and transfer on and off toilet/commode.

0 Able to get to and from the toilet andtransfer independently with or without a device.

1 When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.

2 Unable to get to and from the toilet but is able to use abedside commode (with or without assistance).

3 Unable to get to and from the toilet or bedside commodebut is able to use a bedpan/urinal independently.

4 Is totally dependent in toileting.

Enter Code

VC/SBA MIN MOD MAX D Task Comments/Assist Device

Transfers: Bed

Wheelchair

Toilet

Tub/Shower

Car

Bed Mobility: Roll/Turn

Sit/Supine

Sit/Stand

Transfer Assessment:

Previous level:_________________________________________________

Current level:______________________________________________________

❑ Appears Functional ❑ Additional Training Required

I

MIN MOD MAX D Task Comments/Assist DeviceClothing ManagementToilet Hygiene

Toileting Assessment:

Previous level:_________________________________________________

Current level:______________________________________________________

I VC/SBA

Check appropriate responses. KEY: I - Independent, VC/SBA - Verbal Cues/Stand-by Assist, MIN - Minimum Assist, MOD - Moderate Assist, MAX - Maximum Assist, D - Totally Dependent

I VC/SBA MIN MOD MAX D Task Comments/Assist Device

Comb Hair

Shaving/Make-up

Oral Hygiene

Fingernail Care

Wash Face/Hands

For testing patient/client:❑ Standing❑ Sitting, surfaces❑ Teeth ❑ Dentures:

❑ Upper❑ Lower❑ Partial


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Level UnevenGait Assessment: Stairs OtherSurfaces Surfaces

Distance

Assistance

Assistive Device

Quality/Deviations

Enter Code

(M1860) Ambulation/Locomotion: Current ability to walk safely, once ina standing position, or use a wheelchair, once in a seated position, on avariety of surfaces.

0 Able to independently walk on even and uneven surfacesand negotiate stairs with or without railings (specifically:needs no human assistance or assistive device).

1 With the use of a one-handed device (for example, cane,single crutch, hemi-walker), able to independently walk oneven and uneven surfaces and negotiate stairs with orwithout railings.

2 Requires use of a two-handed device (for example, walkeror crutches) to walk alone on a level surface and/orrequires human supervision or assistance to negotiatestairs or steps or uneven surfaces.

3 Able to walk only with the supervision or assistance ofanother person at all times.

4 Chairfast, unable to ambulate but is able to wheel self independently.

5 Chairfast, unable to ambulate and is unable to wheel self.

6 Bedfast, unable to ambulate or be up in a chair.

HH ★PAO R$P

Enter Codes in Boxes

(GG0170C) Mobility

Code the patient’s usual performance at the SOC/ROC using the 6-point scale. If activity was not attempted at SOC/ROC, code the reason.Code the patient’s discharge goal using the 6-point scale. Do not use codes 07, 09, or 88 to code discharge goal.

Lying toSitting onSide of Bed:The ability tosafely movefrom lying onthe back tositting on theside of thebed with feetflat on thefloor, andwith no backsupport.

Coding:Safety and Quality of Performance – If helper assistance is required because patient’s performance isunsafe or of poor quality, score according to amount of assistance provided.Activity may be completed with or without assistive devices.

06 Independent – Patient completes the activity by him/herself with no assistance from a helper.

05 Setup or clean-up assistance – Helper SETS UP or CLEANS UP; patient completes activity. Helperassists only prior to or following the activity.

04 Supervision or touching assistance – Helper provides VERBAL CUES or TOUCHING/STEADYINGassistance as patient completes activity. Assistance may be provided throughout the activity or intermittently.

03 Partial/moderate assistance – Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.

02 Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holdstrunk or limbs and provides more than half the effort.

01 Dependent – Helper does ALL of the effort. Patient does none of the effort to complete the activity.Or, the assistance of 2 or more helpers is required for the patient to complete the activity.

If activity was not attempted, code reason:

07 Patient refused

09 Not applicable

88 Not attempted due to medical condition or safety concerns

1.SOC/ROC

Performance

2.Discharge

Goal

➔ ➔



SECTION GG: FUNCTIONAL ABILITIES AND GOALS – SOC/ROCPatient Name______________________________________________________________________________________________________ ID #________________________________________


Muscle Tone:___________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Posture:________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Endurance:_____________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Weight Bearing Status: (specify extremities)________________________

_______________________________________________________________

________________________________________________________________

❑ FWB ❑ WBAT ❑ PWB ❑ TDWB ❑ NWB

Assistive Device(s): ❑ Cane ❑ Quad Cane ❑ Hemi Walker

❑ Walker ❑ Wheeled Walker ❑ Other:__________________________

Comments:______________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

(Check all applicable items)

Sitting Static ❑ Good ❑ Fair ❑ Poor

Sitting Dynamic ❑ Good ❑ Fair ❑ Poor

Standing Static ❑ Good ❑ Fair ❑ Poor

Standing Dynamic ❑ Good ❑ Fair ❑ Poor

Standardized Balance Assessment Used and Results:

Tinetti:_________ BERG:_________ Timed Up and GO:_________

Other: _____________________________________________________

CURRENT FINDINGS/GAIT EVALUATION

ADL/IADLs (Cont’d)


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MINI MOD MAX U Task Comments/Assist DeviceLip ClosureAbility to swallowAbility to bringfood/drink to mouth

❑ Evaluate furtherAdaptive ❑ Useddevices: ❑ Not used

KEY: I - Intact, MIN - Minimum Impairment, MOD - Moderate Impairment, MAX - Maximum Impairment, U - Untested

Enter Code

(M1900) Prior Functioning ADL/IADL: Indicate the patient’s usual ability with everyday activities prior to his/her most recent illness, exacerbation, or injury.

a. Self-Care (specifically: grooming, dressing, bathing, andtoileting hygiene)0 Independent1 Needed Some Help2 Dependent

b. Ambulation0 Independent1 Needed Some Help2 Dependent

c. Transfer0 Independent1 Needed Some Help2 Dependent

d. Household tasks (specifically: light meal preparation, laundry, shopping, and phone use)0 Independent1 Needed Some Help2 Dependent

R

Enter Code

Enter Code

Enter Code

Enter Code

(M1890) Ability to Use Telephone: Current ability to answer the phonesafely, including dialing numbers, and effectively using the telephone tocommunicate.

0 Able to dial numbers and answer calls appropriately andas desired.

1 Able to use a specially adapted telephone (for example,large numbers on the dial, teletype phone for the deaf)and call essential numbers.

2 Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.

3 Able to answer the telephone only some of the time or isable to carry on only a limited conversation.

4 Unable to answer the telephone at all but can listen ifassisted with equipment.

5 Totally unable to use the telephone.NA Patient does not have a telephone.

Indications for Home Health Aides: ❑ Yes ❑ No ❑ Refused

Order obtained: ❑ Yes ❑ No

Reason for need: ________________________________________________

________________________________________________________________

________________________________________________________________

M1910 is on page 16 of 27

O R

Enter Code

(M1880) Current Ability to Plan and Prepare Light Meals (for example,cereal, sandwich) or reheat delivered meals safely:

0 (a) Able to independently plan and prepare all light mealsfor self or reheat delivered meals; OR

(b) Is physically, cognitively, and mentally able to preparelight meals on a regular basis but has not routinely performed light meal preparation in the past (specifically: prior to this home care admission).

1 Unable to prepare light meals on a regular basis due tophysical, cognitive, or mental limitations.

2 Unable to prepare any light meals or reheat any deliveredmeals.

O R



Patient Name______________________________________________________________________________________________________ ID #________________________________________

MEDICATIONS

ALLERGIES

ACTIVITIES PERMITTED

Allergies: ❑ None known ❑ Aspirin ❑ Penicillin ❑ Sulfa ❑ Pollen ❑ Eggs ❑ Milk products ❑ Insect bites

❑ Other:_________________________________________________________

_______________________________________________________________


ADL/IADLs (Cont’d)

(M2001) Drug Regimen Review: Did a complete drug regimen reviewidentify potential clinically significant medication issues?

0 No - No issues found during review [Go to M2010]1 Yes - Issues found during review9 NA - Patient is not taking any medications [Go to M2040]

R

Enter Code

(M2003) Medication Follow-up: Did the agency contact a physician (orphysician-designee) by midnight of the next calendar day and completeprescribed/recommended actions in response to the identified potentialclinically significant medication issues?

0 No

1 Yes

Enter Code

(M2010) Patient/Caregiver High-Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-riskmedications (such as hypoglycemics, anticoagulants, etc.) and how andwhen to report problems that may occur?

0 No1 YesNA Patient not taking any high-risk drugs OR patient/care-

giver fully knowledgeable about special precautionsassociated with all high-risk medications

Enter Code

P

P

❑ Complete bedrest❑ Bathroom privileges❑ Up as tolerated❑ Transfer bed/chair❑ Exercises prescribed❑ Partial weight bearing❑ Independent in home❑ Crutches❑ Cane❑ Wheelchair❑ Walker

❑ No restrictions

❑ Other (specify): _____________________

___________________________________

___________________________________

❑ Other (specify): _____________________

___________________________________

___________________________________

❑ Other (specify): _____________________

___________________________________

___________________________________

Enter Code

(M1870) Feeding or Eating: Current ability to feed self meals andsnacks safely. Note: This refers only to the process of eating, chewing,and swallowing, not preparing the food to be eaten.

0 Able to independently feed self.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.

2 Unable to feed self and must be assisted or supervised through out the meal/snack.

3 Able to take in nutrients orally and receives supplementalnutrients through a nasogastric tube or gastrostomy.

4 Unable to take in nutrients orally and is fed nutrientsthrough a nasogastric tube or gastrostomy.

5 Unable to take in nutrients orally or by tube feeding.

PAO R

Feeding/Eating Assessment:

Previous level (specifically: before this home care admission):

______________________________________________________________

______________________________________________________________

______________________________________________________________


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(M2020) Management of Oral Medications: Patient’s current ability toprepare and take all oral medications reliably and safely, includingadministration of the correct dosage at the appropriate times/intervals.Excludes injectable and IV medications. (NOTE: This refers to ability,not compliance or willingness.)

0 Able to independently take the correct oral medication(s)and proper dosage(s) at the correct times.

1 Able to take medication(s) at the correct times if:

(a) individual dosages are prepared in advance by another person; OR

(b) another person develops a drug diary or chart.

2 Able to take medication(s) at the correct times if givenreminders by another person at the appropriate times

3 Unable to take medication unless administered by another person.

NA No oral medications prescribed.

Enter Code

HH PAO R

(M2030) Management of Injectable Medications: Patient’s currentability to prepare and take all prescribed injectable medications reliablyand safely, including administration of correct dosage at the appropriatetimes/intervals. Excludes IV medications.

0 Able to independently take the correct medication(s) andproper dosage(s) at the correct times.

1 Able to take injectable medication(s) at the correct times if:

(a) individual syringes are prepared in advance byanother person; OR

(b) another person develops a drug diary or chart.

2 Able to take medication(s) at the correct times if givenreminders by another person based on the frequency ofthe injection

3 Unable to take injectable medication unless administeredby another person.

NA No injectable medications prescribed.

Enter Code

O R



Patient Name______________________________________________________________________________________________________ ID #________________________________________

(M2040) Prior Medication Management: Indicate the patient’s usualability with managing oral and injectable medications prior to his/hermost recent illness, exacerbation or injury.

Psychotropic drug use: ❑ No ❑ Yes (see med sheet)

Financial ability to pay for medications: ❑ Yes ❑ No

If no, was MSW referral made? ❑ Yes ❑ No/comment:_____________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________


R

MEDICATIONS (Cont’d) MOTOR COMPONENTS

Enter Code

Enter Code

a. Oral medications0 Independent1 Needed Some Help 2 DependentNA Not Applicable

b. Injectable medications0 Independent1 Needed Some Help 2 DependentNA Not Applicable

I MIN MOD MAX U CommentsFine Motor Coordination

Gross Motor Coordination

Left

Right

SENSORY/PERCEPTUAL MOTOR SKILLS

INFUSION

Tonicity: ❑ WNL ❑ Hypertonic ❑ Hypotonic

Describe:_________________________________________________________

__________________________________________________________________

__________________________________________________________________

Left

Right

AreaPerceptual

TestingSensoryTesting

RIGHT LEFT RIGHT LEFT

KEY: I – Intact, MIN – Minimal Impairment, MOD – ModerateImpairment, MAX - Maximum Impairment, U - Untested

Visual Tracking:_________________________________________________

R/L Discrimination:______________________________________________

Motor Planning Praxis:__________________________________________

Do sensory/perceptual impairments affect safety? ❑ Yes ❑ No

If Yes, recommendations:_________________________________________

________________________________________________________________

________________________________________________________________

Comments/Other Impairments Noted:______________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

❑ N/A

Location of site:__________________________________________________

Who manages: ❑ Infusions ❑ Dressing changes ❑ Flushes ❑ Equipment

Name/Relationship:

______________________________________________________________

Are there any signs/symptoms of infection at the site (e.g. redness,swelling, tenderness, etc)? ❑ No ❑ Yes

If yes, explain what action was taken:

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________


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Enter Code



Patient Name______________________________________________________________________________________________________ ID #________________________________________

CARE MANAGEMENT(M2102) Types and Sources of Assistance: Determine the ability and willingness of non-agency caregivers (such as family members, friends, orprivately paid caregivers) to provide assistance for the following activities, if assistance is needed. Excludes all care by your agency staff.

(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 2 Three or more times per week3 One to two times per week4 Received, but less often than weekly5 No assistance receivedUK Unknown

a. ADL assistance (for example, transfer/ambulation, bathing, dressing, toileting, eating/feeding)

0 No assistance needed – patient is independent or does not have needs in this area

1 Non-agency caregiver(s) currently provide assistance

2 Non-agency caregiver(s) need training/ supportive services to provide assistance

3 Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance

4 Assistance needed, but no non-agency caregiver(s) available

b. IADL assistance (for example, meals, house keeping, laundry, telephone, shopping, finances)






c. Medication administration (for example, oral, inhaled or injectable)






d. Medical procedures/treatments (for example, changing wound dressing, home exercise program)






e. Management of Equipment (for example, oxygen, IV/ infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies)






f. Supervision and safety (for example, due to cognitive impairment)






g. Advocacy or facilitation of patient’s participation in appropriate medical care (for example, transportation to or from appointments)







PAR

R

Enter Code

Enter Code

Enter Code

Enter Code

Enter Code

Enter Code

Enter Code


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CARE PREFERENCES/PATIENT’S PERSONAL GOALS REFUSED CARESPatient Name______________________________________________________________________________________________________ ID #________________________________________

Based upon the patient’s comprehensive assessment (physical, psychosocial, cognitive and mental status):

List the patient’s strengths that contribute to them meeting their goal(s),both personal and the HHA measurable goals. For example, involvedfamily, interest in returning to prior activities, cheerful attitude, cooperative, etc.

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

List the patient’s limitations that might challenge progress toward theirgoal(s), both personal and the HHA measurable goal. For example, limited nutritional or financial resources, unsafe environment, multipleanimals sharing the living space, etc.

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

How might the patient’s limitation(s) affect their safety and/or progress?

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Note: CMS is looking for potential issues that may complicate or interfere with the delivery of the HHA services and the patient’s ability toparticipate in his or her own plan of care.

Did the ❑ Patient ❑ Representative ❑ Other:______________________communicate care preferences that involve the home health providedservices?

For example, preferred visit times or days, etc. ❑ No ❑ Yes

If yes, list preferences:____________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Did the ❑ Patient ❑ Representative ❑ Other:______________________communicate any specific personal goal(s) the patient would like toachieve from this home health admission? For example, in the futurethey would like to shop at the mall, shop for their own food or go to afamily wedding etc. ❑ No ❑ Yes

If yes, the ❑ Patient ❑ Representative ❑ Other:_____________________discussed/communicated about the goal(s) with the assessing clinicianand: (check all that apply)

❑ Agreed their personal goal(s) was realistic based on the patient’shealth status.

❑ Agreed their personal goal(s) needed to be modified based on thepatient’s health status.

❑ Agreed to and identified actions/interventions the patient is willing tosafely implement, so the patient will be able to meet their goal(s) bythe anticipated discharge date.

❑ The ❑ Patient ❑ Representative ❑ Other:______________________helped write a measurable goal(s), understandable to all stakeholders.

❑ The ❑ Patient ❑ Representative ❑ Other:______________________was informed, appeared to understand and agreed the personalgoal(s) would be added to the patient’s individualized plan of care andsubmitted to the physician responsible for reviewing and signing theplan of care.

❑ Other:________________________________________________________

❑ Other:________________________________________________________

Resumption of Care: ❑ No change(s) ❑ Goal(s) changed

List all the patient’s goal(s) and indicate if “E”–Existing, “N”–New, “M”–Modified existing or “D”–Discontinued.________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Note: The IMPACT Act requires HHAs to take into account patientgoal(s) and preferences in discharge and transfer planning. This processstarts upon admission/resumption of care.


STRENGTHS/LIMITATIONS

Did the ❑ Patient ❑ Representative ❑ Other:______________________

refuse ❑ care(s) ❑ service(s) in advance? ❑ No ❑ Yes

If yes, explain:___________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Could the ❑ care(s) ❑ service(s) they refused significantly affect the recommended plan of care? ❑ No ❑ Yes

If yes, explain how:______________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________


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Safety Measures:❑ Bleeding precautions❑ O2 precautions❑ Seizure precautions❑ Fall precautions

❑ Aspiration precautions❑ Siderails up❑ Elevate head of bed❑ 24 hr. supervision

❑ Clear pathways❑ Lock w/c with transfers❑ Infection control measures❑ Walker/cane

❑ Other:______________________________________________________________________________________________________________________________________________________________



LIVING ARRANGEMENTS/SUPPORTIVE ASSISTANCEPatient Name______________________________________________________________________________________________________ ID #________________________________________

HOME ENVIRONMENT SAFETY

Safety hazards in the home:

Unsound structure ❑ Yes ❑ No

Inadequate heating/cooling/electricity ❑ Yes ❑ No

Inadequate sanitation/plumbing ❑ Yes ❑ No

Inadequate refrigeration ❑ Yes ❑ No

Unsafe gas/electrical appliances or outlets ❑ Yes ❑ No

Inadequate running water ❑ Yes ❑ No

Unsafe storage of supplies/equipment ❑ Yes ❑ No

No telephone available and/or unable to use phone ❑ Yes ❑ No

Insects/ rodents ❑ Yes ❑ No

Medications stored safely ❑ Yes ❑ No

Grab bar(s) in bathroom / tub /shower ❑ Yes ❑ No

Emergency planning/fire safety:

Fire extinguisher ❑ Yes ❑ No

Smoke detectors on all levels of home ❑ Yes ❑ No

Tested and functioning ❑ Yes ❑ No

More than one exit ❑ Yes ❑ No

Plan for exit ❑ Yes ❑ No

Plan for power failure ❑ Yes ❑ No

CO detector ❑ Yes ❑ No

Oxygen use:

Signs posted ❑ Yes ❑ No

Handles smoking/ flammables safely ❑ Yes ❑ No

Oxygen back-up: ❑ Available ❑ Knows how to use

Electrical / fire safety ❑ Yes ❑ No

Is there a need for a Fall Risk Plan? ❑ Yes ❑ No

Safety plan(s) indicated? ❑ Yes ❑ No

________________________________________________________________

________________________________________________________________

________________________________________________________________

Comments: _____________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Instructions/Materials Provided (Check all applicable items)

❑ Rights and responsibilities

❑ State hotline number

❑ Advance directives

❑ Do not resuscitate (DNR)

❑ HIPAA Notice of Privacy Practices

❑ OASIS Privacy Notice

❑ Emergency planning in the event service is disrupted

❑ Agency phone number/after hours number


EMERGENCY PREPAREDNESS CARE PLANNINGComplete this section per agency policy for applicable activities completedduring this visit. (check all that apply)

❑ Emergency Priority Code assigned to this patient is _______________ based upon the comprehensive assessment of their functional,medical condition, psychosocial situation, cognitive, mental statusand any significant care needs.

(Note: Record the code on the front page of this form and other placesper agency policy)

❑ Obtained the patient’s emergency contact number(s) for the medicalrecord

❑ Discussed the HHA’s plans for supporting their patients during a natural or man-made disaster

❑ Discussed patient specific emergency planning options

❑ Discussed the development of the patient’s individualized emergencypreparedness plan of care, including self-care readiness and the procedure to follow up with the HHA in the event services are interrupted

❑ If applicable, ❑ local utility companies ❑ local emergency officesnotified of life supporting equipment being used

❑ State and local emergency preparedness officials notified about thepossible need for evacuation

❑ List of recommended items to have prepared/ready and available inthe event of an emergency

❑ Educational materials provided to suggest/assist with emergencymanagement/decision making priorities

❑ List of local and state approved evacuation routes and communityshelters relevant to the patient’s specific geographic location

❑ Written materials to restate/reinforce the emergency preparednessprocedures given to the ❑ Patient ❑ Representative (if any)

❑ Caregiver ❑ Other:____________________________________________

Comments: _____________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Instructions/Materials Provided (Cont’d)

❑ When to contact physician and/or agency

❑ Standard precautions/handwashing

❑ Basic home safety

❑ Disease (specify):______________________________________________

❑ Medication regimen/administration

❑ Administrator’s contact information

❑ Copy of Rights & Responsibilities and transfer/discharge policies toRepresentative (HHA has 4 business days)

❑ Other:________________________________________________________

_______________________________________________________________

_______________________________________________________________


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RISK FACTORS/HOSPITAL ADMISSION/EMERGENCY ROOM

Patient Name______________________________________________________________________________________________________ ID #________________________________________


Risk factors identified and followed up on by: ❑ Discussion ❑ Education ❑ Training

Literature given to: ❑ Patient ❑ Representative ❑ Caregiver ❑ Family Member ❑ Other:________________________________________________

List identified risk factors the patient has related to an unplanned hospital admission or an emergency department visit (M1034 and M1036).

______________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________

❑ N/A

Note: Following a patient’s hospital discharge, HHA are required by CMS to include an assessment of the patient’s level of risk for hospital ED visitsand hospital admission. Interventions are required in the patient’s plan of care. When assessing the patient, pay particular attention to patients withCHF, AMI, COPD, CABG, pneumonia, diabetes or hip and knee replacements. Consider these factors co-morbidities, multiple medications, low healthliteracy level, history of falls, low socioeconomic level, dyspnea, safety, confusion, chronic wounds, depression, lives alone, support system, etc.

(Check all that apply)❑ Patient ❑ Caregiver ❑ Representative ❑ Family knowledgeable and able to verbalize and/or demonstrate independence with:

Wound care: ❑ Yes ❑ No ❑ N/A

Diabetic ❑ Foot exam ❑ Care: ❑ Yes ❑ No ❑ N/A

Insulin administration: ❑ Yes ❑ No ❑ N/A

Glucometer use: ❑ Yes ❑ No ❑ N/A

Nutritional management: ❑ Yes ❑ No ❑ N/A

❑ Patient ❑ Caregiver ❑ Representative ❑ Family needs further ❑ education ❑ training with:_______________________________________________

_____________________________________________________________________________________________________________________________________

❑ Caregiver ❑ Representative ❑ Family present at time of visit: ❑ Yes ❑ No ❑ Patient ❑ Caregiver ❑ Representative ❑ Family educated this

visit for (specify):__________________________________________________________________________________________________________________

❑ Patient ❑ Caregiver ❑ Representative ❑ Family appears to understand all information given: ❑ Yes ❑ No

Educated ❑ Patient ❑ Caregiver ❑ Representative ❑ Family about an action plan for when disease symptoms exacerbate (e.g., when to call the homecare nurse vs. emergency services): ❑ Yes ❑ No

Comment(s):________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________

PATIENT/CAREGIVER/REPRESENTATIVE/FAMILY EDUCATION AND TRAINING

❑ Oral ❑ Injected ❑ Infused ❑ Inhaled medication(s) administration: ❑ Yes ❑ No ❑ N/A

Pain management: ❑ Yes ❑ No ❑ N/A

Oxygen use: ❑ Yes ❑ No ❑ N/A

Use of medical devices: ❑ Yes ❑ No ❑ N/A

Catheter care: ❑ Yes ❑ No ❑ N/A

Trach care: ❑ Yes ❑ No ❑ N/A

Ostomy care: ❑ Yes ❑ No ❑ N/A

Other care(s):_____________________

_________________________________

THERAPY NEED 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 physical, occupational 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:

Plan / Intervention No Yes Not Applicable

a. Patient-specific parameters for notifying physician ofchanges in vital signs or other clinical findings

b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities andpatient/caregiver education on proper foot care

c. Falls prevention interventions

d. Depression intervention(s) such as medication, referralfor other treatment, or a monitoring plan for currenttreatment and/or physician notified that patientscreened positive for depression

e. Intervention(s) to monitor and mitigate pain

f. Intervention(s) to prevent pressure ulcers

g. Pressure ulcer treatment based on principles of moistwound healing OR order for treatment based on moistwound healing has been requested from physician

Physician has chosen not to establish patient- specificparameters for this patient. Agency will use standardizedclinical guidelines accessible for all care providers to reference.

Patient is not diabetic or is missing lower legs due to congenital or acquired condition (bilateral amputee).

Falls risk assessment indicates patient has no risk for falls.

Patient has no diagnosis of depression AND depressionscreening indicates patients has: 1) no symptoms ofdepression; or 2) has some symptoms of depression butdoes not meet criteria for further evaluation of depressionbased on screening tool used.

Pain assessment indicates patient has no pain.

Pressure ulcer risk assessment (clinical or formal) indicatespatient is not at risk of developing pressure ulcers.

Patient has no pressure ulcers OR has no pressure ulcersfor which moist wound healing is indicated.

❑ 0

❑ 0

❑ 0

❑ 0

❑ 0

❑ 0

❑ 0

❑ 1

❑ 1

❑ 1

❑ 1

❑ 1

❑ 1

❑ 1

❑ NA

❑ NA

❑ NA

❑ NA

❑ NA

❑ NA

❑ NA

P

$ R

HH

( )


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DME Company:_________________________________________________________ Phone:__________________

Oxygen Company:______________________________________________________ Phone:__________________

❑ Community Organizations ❑ Services:______________________________________________________________________________________________

___________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________

Contact:_______________________________________________________________ Phone:__________________

Comments:_________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________



REHABILITATION POTENTIAL FOR ANTICIPATED DISCHARGE PLANNINGPatient Name______________________________________________________________________________________________________ ID #________________________________________

DME/MEDICAL SUPPLIES

❑ NONE USED

WOUND CARE:❑ 2x2’s❑ 4x4’s❑ ABD’s❑ Cotton tipped applicators❑ Drain sponges❑ Hydrocolloids❑ Kerlix size________________❑ Nu-gauze❑ Saline❑ Tape❑ Transparent dressings❑ Wound cleanser❑ Wound gel❑ Other____________________

__________________________________________________

IV SUPPLIES:❑ Alcohol swabs❑ Angiocatheter size_________❑ Batteries size_____________❑ Central line dressing❑ Extension tubings❑ Infusion pump❑ Injection caps

IV SUPPLIES (Cont’d):❑ IV pole❑ IV start kit❑ IV tubing❑ Syringes size _____________❑ Tape❑ Other____________________

__________________________________________________

URINARY/OSTOMY:❑ External catheters❑ Ostomy pouch (brand, size)

_________________________❑ Ostomy wafer (brand, size)

_________________________❑ Skin protectant❑ Stoma adhesive tape❑ Underpads❑ Urinary bag ❑ Pouch❑ Other____________________

__________________________________________________

FOLEY SUPPLIES:❑ Acetic acid❑ ______Fr catheter kit

(tray, bag, foley)

FOLEY SUPPLIES (Cont’d):❑ Irrigation tray❑ Saline❑ Straight catheter❑ Other____________________

__________________________________________________

DIABETIC:❑ Chemstrips❑ Syringes❑ Other____________________

_________________________

MISCELLANEOUS:❑ Enema supplies❑ Feeding tube:

type_________ size ________❑ Gloves:

❑ Sterile ❑ Non-sterile❑ Staple removal kit❑ Steri strips❑ Suture removal kit❑ Other____________________

____________________________________________________________________________________________________

SUPPLIES/EQUIPMENT:❑ Augmentative and

alternative communication device(s) (type)__________________________________________________

❑ Bath bench❑ Brace ❑ Orthotics (specify)

__________________________________________________

❑ Cane❑ Commode❑ Dressing Aid Kit /Hip Kit

(e.g. reacher, long handlesponge, long handle shoehorn, etc.)

❑ Eggcrate❑ Enteral feeding pump❑ Grab bars: Bathroom/Other

__________________________________________________

❑ Hospital bed: ❑ Semi-electric

❑ Hoyer lift❑ Knee scooter❑ Medical alert❑ Nebulizer

SUPPLIES/EQUIPMENT(Cont’d)❑ Oxygen concentrator❑ Pressure relieving device

_________________________❑ Prosthesis: ❑ RUE ❑ RLE

❑ LUE ❑ LLE ❑ Other:__________________________________________________

❑ Raised toilet seat❑ Special mattress overlay

_________________________❑ Suction machine❑ TENS unit❑ Transfer equipment:

❑ Board ❑ Lift ❑ Ventilator❑ Walker❑ Wheelchair❑ Other Supplies Needed

_______________________________________________________________________________________________________________________________________________________________________________


CARE PLAN: Collaboration with: ❑ Patient ❑ Caregiver ❑ Representative ❑ Family involvement

MEDICATION STATUS: ❑ Medication regimen completed/reviewed ❑ No change ❑ Order obtained

Check if any of the following were identified:

❑ Potential adverse effects ❑ Drug reactions

❑ Ineffective drug therapy ❑ Significant side effects

❑ Significant drug interactions ❑ Duplicate drug therapy

❑ Non-compliance with drug therapy

CARE COORDINATION: ❑ Certifying Physician ❑ PT ❑ OT ❑ SLP ❑ MSW ❑ Aide ❑ Other (specify):___________________________________

Was a referral made to MSW for assistance with: ❑ Community resources ❑ Living will ❑ Counseling needs ❑ Unsafe environment

❑ Other:_____________________________________________________________________________________________________________________________

Date:_________________ ❑ Yes ❑ No ❑ Refused ❑ N/A

Comments:_________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________

Verbal Order obtained: ❑ No ❑ Yes, specify date:________________

SUMMARY CHECKLIST

❑ Return to an independent level of care (self-care)

❑ Able to remain in residence with assistance of: ❑ Primary Caregiver ❑ Support from community agencies

❑ Restorative Potential, based on clinical objective assessment and evidence based knowledge the patient's condition is likely to undergo functionalimprovement and benefit from rehabilitative care

❑ Discussed discharge plan with: ❑ Patient ❑ Representative ❑ Other:______________________________________________________________________


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PROFESSIONAL SERVICES WORKSHEETPatient Name______________________________________________________________________________________________________ ID #________________________________________

REHABILITATION/POTENTIAL GOALS WORKSHEETCheck goal(s) and insert information. Check box to indicate short or long term goal(s).


Date Reviewed______________________ Date Entered & Locked______________________ Date Transmitted______________________

OASIS INFORMATION

SIGNATURES/DATES

X________________________________________________________________________________ ______________________ ________________Patient/Family Member/Caregiver/Representative (if applicable) Date Time

________________________________________________________________________________ ______________________ ________________Person Completing This Form (signature/title) Date Time

DISCIPLINE GOALS AND DATE WILL BE ACHIEVED❑ Demonstrate effective pain management within ______ weeks. ❑ Short ❑ Long

❑ Improve bed mobility to _____________ assist within ______ weeks. ❑ Short ❑ Long

❑ Improve bed mobility to independent within ______ weeks. ❑ Short ❑ Long

❑ Improve transfers to _____________ assist using ____________ within ______ weeks. ❑ Short ❑ Long

❑ Independent with transfer skills within ______ weeks. ❑ Short ❑ Long

❑ Patient to be independent with safety issues in ______ weeks. ❑ Short ❑ Long

❑ Improve wheelchair use to _____________ within ______ weeks. ❑ Short ❑ Long

❑ Patient will ambulate with __________________________ (device) for ____________ (distance) with ____________ assist within ______ weeks.

This will allow them to ________________________________________. ❑ Short ❑ Long

❑ Patient will be able to climb stairs/uneven surfaces with __________________________ (device) with ____________ assist within ______ weeks.

This will allow them to ________________________________________. ❑ Short ❑ Long

❑ Ambulation endurance will be ______ minutes or ______ feet within ______ weeks. ❑ Short ❑ Long

❑ Increase strength of ❑ R ❑ L UE to ______/5 in ______ weeks to allow patient to perform the following activity ____________________________

____________________________________________________. ❑ Short ❑ Long

❑ Increase strength of ❑ R ❑ L LE to ______/5 in ______ weeks to allow patient to perform the following activity ____________________________

____________________________________________________. ❑ Short ❑ Long

❑ Improve strength of _________________________ to ______/5 within ______ weeks to allow patient to perform the following activity

____________________________________________________. ❑ Short ❑ Long

❑ Increase ROM of _________________ joint to ______ degree flexion and ______ degree extension in ______ weeks to allow patient to perform

the following activity____________________________________________________. ❑ Short ❑ Long

❑ Increase ROM of _________________ joint to ______ degree of _____________ in ______ weeks to allow patient to perform the following

activity____________________________________________________________. ❑ Short ❑ Long

❑ Demonstrate ROM to WNL within ______ weeks to allow patient to perform the following activity __________________________________________

____________________________________________________. ❑ Short ❑ Long

❑ Demonstrate proper use of prosthesis/brace/splint within ______ weeks. ❑ Short ❑ Long

❑ Demonstrate proper use of DME within ______ weeks. ❑ Short ❑ Long

❑ Patient will have an increase in Tinetti Balance score to ______/28 within ______ weeks. ❑ Short ❑ Long

❑ Improve balance score to ___________ using _______________ test. ❑ Short ❑ Long

❑ Other:________________________________________________________________________________ within ______ weeks. ❑ Short ❑ Long

❑ Other:________________________________________________________________________________ within ______ weeks. ❑ Short ❑ Long

OT - FREQUENCY/DURATION:

_______________________________________________________❑ Evaluation and Treatment❑ Pulse Oximetry PRN❑ Home Safety/Falls Prevention❑ Adequate Equipment❑ Therapeutic Exercise❑ Muscle Re-Evaluation❑ Establish Home Exercise Program❑ Homemaker Training❑ Modality (specify frequency, duration, amount)

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❑ Physical Therapy to evaluate and treat❑ Speech Therapy to evaluate and treat❑ Nursing to evaluate and treat❑ Medical Social Services to evaluate and treat❑ Aide to assume responsibility for personal care needs

by __________________ (date)

Comments:______________________________________________________________

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Patient Name______________________________________________________________________________________________________ ID #________________________________________

SIGNATURE/DATE

X_______________________________________________________________________________________ ______________________ __________________Person Completing This Form (signature/title) Date Time

__________________________________________________________________________________________ _____________________________________Agency Name Phone Number

PHYSICIAN VERBAL ORDER (Complete if applicable per agency policy)

❑ Physician (name)___________________________________________ called to report comprehensive assessment findings (including medical, nursing,rehabilitative, social and discharge planning needs).

❑ Verbal order received to initiate home health intermittent (reasonable and necessary) skilled services for:____________________________________

________________________________________________________________________________________________________________________________(specify amount/ frequency/duration for discipline(s) and treatment(s)

X____________________________________________________________________________________ ______________________ __________________Signature/Title of Person Who Received Verbal Order Date Time

X____________________________________________________________________________________ ______________________ __________________Physician Signature for Verbal Order Date Time


Reason for Admission:____________________________________________ Homebound Reason: _______________________________________________

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ASSESSMENT SUMMARY (Include skilled care provided this visit and analysis of findings)


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OCCUPATIONAL THERAPY COMPREHENSIVE ADULT ASSESSMENT

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