OT OASIS C FOLLOW-UP/RECERT - TriPoint Healthcare

WEST PENN ALLEGHENY HOME CARE
FOLLOW-UP/RECERT
West Penn Allegheny Health System
OT OASIS C
Billable Non Billable
__________________________________ _________ _______ _______ ________
____________
Patient Name: Last/First MR# Payor Time In Time Out
Date
___________________________________ _________ _________
______________________________
Address-Street/Apt City Zip Code
Physician/Phone #
Previous Contact Info:
Date of Visit: _____/_____/_____
Staff: __________________________________________ Discipline ___________________
Plan for Visit:

MO32-Resumption of Care Date _____/_____/_____ NA-Not Applicable
MO80-Discipline of person completing assessment: 1-RN 2-PT 3-SLP/ST 4-OT
MO90-Date Assessment completed: ____/____/____
MO100- This Assessment is Currently Being Completed for the Following Reason:
Follow-Up
04-Recertification (Follow-Up) reassessment
05-Other Follow-up
MO110-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-Early
2-Later
UK-Unknown
NA-Not Applicable No Medicare case mix group to be defined by this assessment
M1020 -Primary & (M1022) Other Diagnoses M1024-Payment Diagnoses (OPTIONAL)
Column 1:Sequencing of Dx should reflect the seriousness of each condition & support disciplines & services
provided)
Column 2:The sequencing of these rating may not match the sequencing of the dx. ICD-9 C M/Symptom Control
rating.
Column 3:Complete if V-code in Col 2 is reported in place of a case mix dx).
Column 4:Complete only if V-code in Col 2 is reported in place of a case mix dx that is a multiple coding situation
(e.g. manifestation code).
M1020) Primary diagnosis (V-code allowed) (V-or E-codes NOT allowed)
a. ____________________ _____________ a. ______________ a. ________________
M1022-Other Diagnoses (Vor E codes allowed) (V or E codes NOT allowed)
b. ____________________ _____________ b. ______________ b. ________________
c. ____________________ _____________ c. ______________ c. ________________
d. ____________________ _____________ d. ______________ d. ________________
e. ____________________ _____________ e. ______________ e. ________________
f. ____________________ _____________ f. ______________ f. ________________
M1030-Therapies the patient receives at home: (Mark all that apply)
1. Intravenous or infusion therapy ( excludes TPN)
2. Parenteral nutrition (PTN or lipids)
3. Enteral nutrition (nasogastric, gastrostomy, jejunoslomy, or any other artificial entry ino the alimentary
canal)
4. None of the above
Temp: __________ _______________
Pulse: __________Radial ___________Apical __________
Regular Irregular At Rest w/Exercise
Blood Pressure: Systolic Diastolic Units Side Position
B/P #1 _______ _______ _______ _______ _______
B/P #2 _______ _______ _______ _______ _______
B/P #3 _______ _______ _______ _______ _______
Respirations: __________ __________ Easy Labored

Patient Name_____________________________________________Date:_____/_____/_____
3
Lung Sounds: Within Normal Limits L Clear R Clear
Left L Diminished L Rales L Rhonchi L wheezes
Right R.Diminished R Rales R Rhonchi R wheezes
Height __________ Pulse Ox #1 _______ __________ At Rest
Weight __________ w/Exercise RA 02
BMI __________ %_________ Pulse Ox #2 _______ ___________ At Rest
BMI=Weight in Pounds divided by w/Exercise RA 02
Height in Inches squared x 703 BMI Notes:
____________________________________________________
to be recorded in whole numbers only.
____________________________________________________
Has the patient had a 10% change in
weight in last 6 Months/____________
Safety Hazards:
No Safety Hazards Structurally Unsound Obstructed Exits/Entrances
Unsafe Mats/Throws
Inadequate Heat Inadequate Lighting Inadequate Plumbing Unsafe Appliances
Lacks Safety Devices Steep Stairs Unsafe Storage of Dangerous Lead Paint
Present
Cluttered Living
Objects/Substances
Arrangements
Other
Fall #1
_____________________ Injury
Location _____________________ MD Notified
____________________________________ Witnessed
Fall #2
_____________________ Injury
Location _____________________ MD Notified
____________________________________ Witnessed
Fall #3
_____________________ Injury
Location _____________________ MD Notified
____________________________________ Witnessed
Reason For Assessment
Admission Recert Post-Fall (Give to Manager when completed)
A. Level of consciousness/Mental Status A. Score: _____
0-Alert and oriented x 3
2-Disoriented x 3 at all times

Patient Name_____________________________________________Date:_____/_____/_____
4
4-Intermittent confusion
B. History of Falls (past 3 months) B. Score _____
0-No falls ( in past 3 months)
2-1-2 falls (in past 3 months)
4-3 or more falls (in past 3 months
C. Ambulation/Elimination Status C. Score _____
0-Ambulatory/continent
2- Chair bound
4-Ambulatory/incontinent
D. Vision Status D. Score: _____
0-Adequate (with or without glasses)
2-Poor (with or without glasses)
4-Legally blind
E. Gait/Balance: to assess the gait/balance, have patient stand on both feet without E. Score: _____
holding onto anything: walk straight forward; walk through a doorway; and
make a turn.
0-Gait/balance normal
1-Balance problem while standing
1-Balance problem while walking
1-Decreased muscular coordination
1-Change in gait pattern when walking through doorway
1-Jerking or unstable when making turns
1-Requires use of assistive device (cane, w/c, furniture..)
F. Orthostatic Changes F. Score: _____
0-No noted drop in blood pressure between lying and standing. No change in cardiac rhythm.
2-Drop 20.
G. Medications: Respond below based on the following types of medications: G. Score: _____
anesthetics, antihistamines, antihypertensives, antiseizure, benzodiazepines,
cathartics, diuretics, hypoglycemics, narcotics, phychotropics, sedatives/hypnotics.
0-None of these medications taken currently on w/in last 7 days
2-Takes 1-2 of these medications currently and/or w/in last 7 days
4-Takes 3-4 of these medications currently and/or w/in 7 days
1-If patient has had a change in medication and/or change in dosage in past 5 days, score + 1 additional point.
H. Medications: Respond below based on the following predisposing conditions: H. Score: ______
hypotension, vertigo, CVA, Parkinson’s disease, loss, of limb(s), seizures, arthritis,
osteoporosis, fractures.
0-None present
2-1-2 present
4-3 or more present
TOTAL SCORE: (score of 10 represents High Risk)
______
Patient informed about the safety/falls prevention recommendations listed in the admission packet ____________

Patient Name_____________________________________________Date:_____/_____/_____
5
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 or newsprint, but can see obstacles in path, and
the surrounding layout; can count fingers at arm’s length
2-Severely impaired: cannot locate objects without hearing or touching them or patient nonresponsive
M1242-Frequency of Pain: Interfering with patient’s activity or movement:
0-Patient has no pain or pain does not interfere with activity or movement
1-Patient has pain that does not interfere with activity or movement
2-Less often than daily
3-Daily, but not constantly
4-All of the time
Location:
Abdomen Arm Back Chest
Generalized Head/Neck Leg Shoulder Other
Patient Describes Pain as: Ache Burning Dull Sharp Stabbing Throbbing
Pain Intensity Level Now: 0 01 02 03 04 05 06 07 08 09 10
Pain Intensity at Worst: 0 01 02 03 04 05 06 07 08 09 10
Pain Intensity at Best: 0 01 02 03 04 05 06 07 08 09 10
Acceptable Level of Pain: 0 01 02 03 04 05 06 07 08 09 10
Pain Quality:
Bone Nerve Somatic Visceral Other Other
Onset: _______________________________________________________________
Frequency: ___________________________________________________________
Duration: Constant Intermittent Occasional With Movement
Note:
Barriers to Pain Control
Culture Education Philosophy of caregiver Physical
Emotional Spiritual Financial Other

Patient Name_____________________________________________Date:_____/_____/_____
6
Pain Relief measures
Rest Other
Current Meds:
Pain Relief Medications & Response:
Effects of Pain Relief Measures ________
Impact on Functional Activity:
Location:
Abdomen Arm Back Chest
Generalized Head/Neck Leg Shoulder Other
Patient Describes Pain as: Ache Burning Dull Sharp Stabbing Throbbing
Pain Intensity Level Now: 0 01 02 03 04 05 06 07 08 09 10
Pain Intensity at Worst: 0 01 02 03 04 05 06 07 08 09 10
Pain Intensity at Best: 0 01 02 03 04 05 06 07 08 09 10
Acceptable Level of Pain: 0 01 02 03 04 05 06 07 08 09 10
Pain Quality:
Bone Nerve Somatic Visceral Other Other
Onset: ______________________________________________________________
Frequency: __________________________________________________________
Duration:
Note:

Patient Name_____________________________________________Date:_____/_____/_____
7
Barriers to Pain Control
Culture Education Philosophy of caregiver Physical
Emotional Spiritual Financial Other
Pain Relief measures
Rest Other
Current Meds:
Pain Relief Medications & Response:
Effects of Pain Relief Measures ________
Impact on Functional Activity:
Location:
Abdomen Arm Back Chest
Generalized Head/Neck Leg Shoulder Other
Patient Describes Pain as:
Ache Burning Dull Sharp Stabbing Throbbing
Pain Intensity Level Now: 0 01 02 03 04 05 06 07 08 09 10
Pain Intensity at Worst: 0 01 02 03 04 05 06 07 08 09 10
Pain Intensity at Best: 0 01 02 03 04 05 06 07 08 09 10
Acceptable Level of Pain: 0 01 02 03 04 05 06 07 08 09 10

Patient Name_____________________________________________Date:_____/_____/_____
8
Pain Quality:
Bone Nerve Somatic Visceral Other Other
Onset: _________________________________________________________________________
Frequency:
Duration:
Note:
____________________________________________________________________
Constant Intermittent Occasional With Movement
Barriers to Pain Control
Culture Education Philosophy of caregiver Physical
Emotional Spiritual Financial Other
Pain Relief measures
Rest Other
Current Meds:
Pain Relief Medications & Response:
Effects of Pain Relief Measures ________
Impact on Functional Activity:
Sensory Perception: Ability to respond meaningfully to pressure-related
Score
discomfort. 1. Completely Limited __________
2. Very Limited
3. Slightly Limited
4. No Improvement
Moisture Degree to which skin is exposed to moisture. 1. Constantly Moist __________

Patient Name_____________________________________________Date:_____/_____/_____
9
2. Very Moist
3. Occasionally Moist
4. Rarely Moist
Activity: Degree of physical activity 1. Bedfast __________
2. Chairfast
3. Walks Occasionally
4. Walks Frequently
Mobility: Ability to change and control body position. 1. Completely Immobile __________
2. Very Limited
3. Slightly Limited
4. No Limitations
Nutrition: Usual food intake pattern. 1. Very Poor __________
2. Probably Inadequate
3. Adequate
4. Excellent
Friction/Shear: 1. Problem ___________
2. Potential Problem
3. No Apparent Problem
Total Branden Risk Score
_____________
Total Branden Risk Score
_____________
BRADEN SCORING: Patients with a score of 16 or less are considered to be at risk of developing pressure ulcers. (15 or 16 +
low risk; 13 or 14+ moderate risk; 12 or less + high risk)
Do you want to attach the Mini Nutritional (MNA) Assessment as a secondary profile
M1306-Does this patient have a least one Unhealed Pressure Ulcer at Stage 11 or Higher or designated as “unstageable”
0-No (go to M1322)
1-Yes
M1308-Current Numbers of Unhealed (non-epithelialized) Pressure Ulcers at Each Stage: (Enter “0" if none; excludes Stage 1
pressure ulcers)
Column 1
Complete at
SOC/ROC/FU/DC
Stage description
Number Currently
Unhealed pressure ulcers
Present
a. Stage 11: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough, May
also present as an intact or open/ruptured serum-filled blister.
Column 1: _______ Column 2: _____
b. Stage 111: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough
may be present but does not obscure the depth of tissues loss. May include undermining and tunneling.
Column 1: _______ Column 2: _____
c. Stage IV: Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the
wound bed. Often includes undermining and tunneling.
Column 1: _______ Column 2: _____
d1. Unstageable: Known or likely but unstageable due to non-removable dressing or device.

Patient Name_____________________________________________Date:_____/_____/_____
10
Column 1: _______ Column 2: _____
d2. Unstageable: Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.
Column 1: _______ Column 2: _____
d3. Unstageable: Suspected deep tissue injury in evolution.
Column 1: _______ Column 2:_____
M1322-Current Number of Stage 1 Pressure 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.
0 1 2 3 4 or more
M1324-Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:
1-Stage 1 2-Stage 11 3-Stage 111 4-Stage IV
M1330-Does this patient have a Stasis Ulcer
0-No (Go to M1340)
1-Yes, patient has BOTH observable and unobservable stasis ulcers.
2-Yes, patient has observable stasis ulcers ONLY
3-Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable
dressing) (Go to M1340)
M1332-Current Number of (Observable) Stasis Ulcer(s):
1-One 2-Two 3-Three 4-Four or more
M1334-Status of Most Problematic (Observable) Stasis Ulcer:
0-Newly 1-Fully 2-Early/partial 3-Not healing
epithelialized granulating granulating
M1340-Does this patient have a Surgical Wound
0-No (Go to M1350)
1-Yes, patient has a least one (observable) surgical wound
2- Surgical wound known but not observable due to non-removable dressing (Go to M1350)
M1342-Status of Most Problematic (Observable) Surgical Wound:
0-Newly 1-Fully 2-Early/partial 3-Not healing
epithelialized granulating granulating
M1350-Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that
is receiving intervention by the home health agency.
0-No 1-Yes
M1400-When is the patient dyspneic or noticeabley short of breath
0-Patient is not short of breath
1-When walking more than 20 feet, climbing stairs.
2-With Moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20
3-With minimal exertion (while eating, talking or performing other ADLs), or with agitation
4- At rest (during day or night)
M1610-Urinary Incontinence or Urinary Catheter Presence:
0-No Incontinence or catheter (includes anuria or ostomy for urinary drainage) -(Go to M1620)
1-Patient is Incontinent
2-Patient requires a urinary catheter (i.e, external, indwelling, intermittent, suprapubic)-(Go to M1620)
M1620-Bowel Incontinence Frequency:
0-Very rarely or never has bowel incontinence 4-On a daily basis
1-Less than once weekly
5-More often than once daily
2-Once to three times weekly
NA-Patient has ostomy for bowel elimination
3-Four to six times weekly
M1630-Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a)
was related to an inpatient facility stay, or b)necessitated a change in medical or treatment
feet

Patient Name_____________________________________________Date:_____/_____/_____
11
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
treatment regimen
2-The ostomy was related to an inpatient stay or did necessitate change in medical or treatment regimen
M1810-Current ability to Dress Upper Body safely (with or without dressing aids), including undergarments, pullovers,
front-opening shirts and blouses, managing zippers, buttons, and snaps:
0-Able to get clothes out of closets and drawers, put them on and remove them from the upper body without
assistance.
1-Able to dress upper body without assistance if clothing is laid 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 (with or without dressing aids) including undergarments, slacks, socks or nylons,
shoes:
0-Able to obtain, put on and remove clothing and shoes without assistance.
1-Able to dress lower body without assistance if clothing is 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 dress the lower body.
M1830-Bathing: Current ability to wash entire body. Excludes grooming (washing face washing hands and shampooing hair):
0-Able to bathe self in shower or tub independently, including getting in and out of tub/shower.
1-With the use of devices, is able to bathe self in shower or tub independently including getting in and out
of tube/shower.
2-Able to bathe in shower or tub with the assistance of anther person:
(a)for intermittent supervision or encouragement or reminders, OR
(b)to get in and out of the shower or tube, OR
(c)for washing difficult to reach areas.
3-Able to participates in bathing self in shower or tub, but requires presence of another person throughout the bath
for assistance or supervision.
4-Unable to participate in bathing self in shower or tub, but able to bathe self independently with or without
the use of devices at the sink, in chair, or on commode.
5-Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on
commode, with the assistance or supervision of another person throughout the bath.
6-Unable to participate effectively in bathing and is bathed totally by another person.
M1840-Toilet transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off
toilet/commode.
0-Able to get to and from the toilet 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 a bedside commode (with or without assistance).
3-Unable to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.
4-Is totally dependent in toileting
M1850-Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if patient in
bedfast.
0-Able to independently transfer.
1-Able to transfer with minimal human assistance or with use of assistive device.
2-Able to bear weight and pivot during 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.

Patient Name_____________________________________________Date:_____/_____/_____
12
5-Bedfast, unable to transfer and is unable to turn and position self.
M1860-Ambulation/Locomotion: Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated
position, on a variety of surfaces.
0-Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e.
needs no human assistance or assistive device).
1-With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk
on even and uneven surfaces and negotiate stairs with or without railings.
2-Requires use of a two-handed device (e.g. walker or crutches) to walk alone on a level surface and/or
requires human supervision or assistance to negotiate stairs with or steps or uneven surfaces.
3-Able to walk only with the supervision or assistance of another 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.
M2030-Management of Injectable medications: Patient’s current ability to prepare and take all prescribed injectable medications
reliably and safely, including administration of correct dosage at the appropriate times/intervals. Excludes IV medications.
0-Able to independently take the correct medication(s) and proper dosage(s) at the correct times.
1-Able to take injectable medication(s) at correct times if: (a) individual syringes 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 given reminders by another person based on the
frequency of the injection.
3-Unable to take injectable medications unless administered by another person.
NA-No injectable medications prescribed.
ADL’s: 0- Independent 1. SBA 2. Min A 3. Mod A 4. Max A 5. Dependent enter in first
column.
Grooming (M1800): ________________ ______________________________________________
Dressing UB (M1810): ________________ ______________________________________________
Dressing LB (M1820): ________________ ______________________________________________
Bathing (M1830): ________________ ______________________________________________
Toileting/Transfer (M1840): ________________ ______________________________________________
Toileting/Hygiene (M1845): ________________ ______________________________________________
Tub/Shower (M1850): ________________ ______________________________________________
Feeding/Eating (M1870): ________________ ______________________________________________
IADL’s:
Cooking/Meal Prep (M1880): _________________ _______________________________________________
Laundry: _________________ _______________________________________________
Household Mgmnt: _________________ _______________________________________________
ADL/IADL’s Notes: _________________ _______________________________________________
Leisure: ___________________________________________________________________________________
Social participation: _________________________________________________________________________________
Therapeutic Exercises:

Patient Name_____________________________________________Date:_____/_____/_____
13
PRE Stretching Muscle Re-Ed
Posture:
Endurance:
Sensation:
Muscle Grade
Range of Motion
AROM PROM AAROM
Choose from the following for
muscle grade 0=Zero, 1-, 1=Trace, 1+, 2-, 2=Gravity min, 2+, 3-
Shoulder:
Flexion Left Left ______ ______ _______
Right Right ______ ______ _______
Extension Left Left ______ ______ _______
Right Right ______ ______ _______
Abduction Left Left ______ ______ _______
Right Right ______ ______ _______
Adduction Left Left ______ ______ _______
Right Right ______ ______ _______
Int Rotation Left Left ______ ______ _______
Right Right ______ ______ _______
Ext Rotation Left Left ______ ______ _______
Right Right ______ ______ _______
Elbow/Forearm
Flexion Left Left ______ ______ _______
Right Right ______ ______ _______
Extension Left Left ______ ______ _______
Right Right ______ ______ _______
Supination Left Left ______ ______ _______

Patient Name_____________________________________________Date:_____/_____/_____
14
Right Right ______ ______ _______
Pronation Left Left ______ ______ _______
Right Right ______ ______ _______
Wrist
Flexion Left Left ______ ______ _______
Right Right ______ ______ _______
Extension Left Left ______ ______ _______
Right Right ______ ______ _______
Ulnar Deviation Left Left ______ ______ _______
Right Right ______ ______ _______
Radical Deviation Left Left ______ ______ _______
Right Right ______ ______ _______
Thumbs
MP Flexion Left Left ______ ______ _______
Right Right ______ ______ _______
IP Extension Left Left ______ ______ _______
Right Right ______ ______ _______
Abduction Left Left ______ ______ _______
Right Right ______ ______ _______
Extension Left Left ______ ______ _______
Right Right ______ ______ ________
Opposition Left Left ______ ______ ________
Right Right ______ ______ ________
Left Fingers Right
Index Middle Ring Little Little Ring Middle Index
MP Flex
PIP Flex
DIP Flex
Abd
Tip-DPC
Functional Hand Strength
Trial #1 Trial #2 Trial #3 Trial #1 Trial #2 Trial #3
Grip
Tip Pinch
Lateral Pinch

Patient Name_____________________________________________Date:_____/_____/_____
15
3 Jaw Chuck
Patient
CG/Other Status Comments
ADL ____________________________________________
Techniques ____________________________________________
Energy ____________________________________________
Conservation ____________________________________________
HEP ____________________________________________
____________________________________________
Safety ____________________________________________
Measures ____________________________________________
Community ____________________________________________
Resources ____________________________________________
Use of ____________________________________________
Adaptive
Equipment _____________________________________________
Other _______________________________________
_______________________________________
M2200-Therapy Need: In the home health plan of care for the Medicare payment episode for which this assessment will define a
case mix group, what is the indicated need for therapy visits (total of reasonable and necessary physical, occupational, and
speech-language pathology visits 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.
Homebound Limitations:
Bed Bound Chair bound Medically restricted to home Other
Unable to ambulate Unable to ambulate None
more than 10ft
more than 20ft
Requires Assistance:
Frequent rest periods Ambulance to leave home Assist of 1 person to ambulate/transfer
Assist of 2 people to Mechanical device for transfer Requires assistance due to mental confusion None
ambulate/transfer
Patient requires following assistive device(s)
Cane Pronged Walker Walker
Wheeled walker Wheelchair Crutches
Specialized Orthotics Prosthesis Oxygen

Patient Name_____________________________________________Date:_____/_____/_____
16
Slideboard None Other
Note:
With activity of leaving home the patient may experience:
Dizziness/vertigo Angina/chest pain Pain
Swelling Respiratory distress/ Unsteady gait/Frequent falls/
dyspnea/SOB
Mental confusion
Serious risk of infection Incontinence of urine
Incontinence of stool None Other
poor balance
Homebound status is primarily due to:
Infected/Drainage/Large/Painful wound Profound generalized weakness Morbid obesity
Orthopedic condition Cardiac condition Neurologic condition
Lung condition Immunosupression Psychological impairment
Peripheral vascular disease Urinary condition Bowel condition
None
Other
Note:
CHHA Name
______________________________________________________________________________
Agency
________________________________________________________________________________________________
Schedule
Orientation to Care
Care Plan Instruction Given
Services Supervised
Services Evaluated
_______/_______/_______Next Scheduled Supervisory Visit
Review of Vulnerabilities:
None Noted Cognition Impairment Substance Abuse

Patient Name_____________________________________________Date:_____/_____/_____
17
Sensory Deficit Impaired Mobility Functional Limitations
Environmental Concerns Dependent upon Caregiver
Other:
Rehab Potential: _____________________________
To Achieve Goals by
Next Visit Date
_______/_______/_______
_______/_______/_______
Plan:
Phone Call Made to: ________________________________________
Details:
____________________________________________________________________________________________
____
Visit Narrative:
To use this form: 1) Select an Active Problem. Based upon this selection, 2) select Active Goals & Interventions 3)
Check “Add Selected G/I” to populate the G/I Addressed This visit text box 4) Return to the Active Problem, select
new Problem 5) Select new G/I 6) Re-check the “Add Selected” box
Active Problems
Active Goals:
Add Selected Goals

Patient Name_____________________________________________Date:_____/_____/_____
18
Goals Addressed This Visit
Active Interventions:
Add Selected intervention
Interventions Addressed This Visit

Patient Name_____________________________________________Date:_____/_____/_____
19
MOO10-CMS Certification Number 397076
MOO14-Branch State PA
MOO16-Branch ID Number (N)
MOO18-National Provider ID 1811997315
MOO20-Patient ID Number
MOO30 Start of care date _______/_______/_______
MOO40-Patient Name (First):____________________(Last): _______________________ (MI): ____
MOO50-Patient State of Residence____________________
MOO60-Patient Zip Code ____________
MOO63-Medicare Number _________________
(Including suffix, if any)
NA-No Medicare
MOO64-Social Security Number ____________
UK-Unknown or Not Available
MOO65-Medicaid Number_________________

Patient Name_____________________________________________Date:_____/_____/_____
20
NA-No Medicaid
MOO66-Birth Date _______/_______/_______
MOO69- 1-Male 2-Female
MO150-Current Payment Sources for Home Care: (Mark all that apply.)
0-None; no charge for current services
9-Private HMO/managed care
1-Medicare (traditional fee-for-service)
10-Self-pay
2-Medicare (HMO/managed care)
11-Other (specify) __________________
3-Medicaid (traditional fee-for-service)
4-Medicaid (HMO/managed care)
5-Workers’ compensation
6-Title programs (e.g., title III, V, or XX)
7-Other government (e.g., CHAMPUS, VA, etc.)
8-Private insurance
Occupational Therapist Signature _______________________________________________________________________