OT OASIS C FOLLOW-UP/RECERT - TriPoint Healthcare

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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
Page 1: WEST PENN ALLEGHENY HOME CARE FOLLO
Page 5 and 6: Patient Name_______________________

OT OASIS C FOLLOW-UP/RECERT - TriPoint Healthcare

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