L
.
HHRG Case MIX Legend: = Clinical Severity Domain
-,,--,",,,,-
..
_--"
- .....~.
.'--..--- .
PHYSICAL THERAPY COMPREHENSIVE ADULT ASSESSMENT
l!rn!] 1m = Functional Status Domain l§l!I!] = Service Utilization Domain
directed. ~
INCLUDING SOC/ROC/OASIS ELEMENTS WITH CMS 485 INFORMA~N rDATE OF SERVICE / b
r"" TIME IN ---' TIME OUT
Follow MOOnumbers In sequence unless otherwise
=
Quality Indicator
i'):qtL
This Patient Tracking Information must be filled out at start of care and per organizational It is to be maintained as part of the clinical record.
(M0010) Agency Medicare (M0012) Agency Medicaid Provider Number: Provider Number:
,,_vv_.V. ,"VTj
pOlicy:
(M0064) Social Security (M0065) Medicaid (M006; _
Number:
0 UK-Unknown or Not Available
Number:
0 NA-No Medicaid
Branch Identification
(M0014) Branch State: __
B~;Date:~L~at~#ilj
-2 cl 0-_ ~~ '?--h
month day year
(M0016) Branch 10 Number: (M0020) Patient 10 Number: i!!-~r 114)
Patient's HI Claim No.: !'-v_uw, •.'1J o 1 - Same as M0063 03 - Other (M0069) Gender: !(locator
Medical Record Number if different than M0020 (M0030) ;a~ o;-C~e~ate: ~o;;;to~2(
!9)1~a;
Physician
0 2-Female -
-
-
X-15
month day
1=1,(5(2'1
year
(M0072) Primary Referring
--------
.
1.0.:
0 UK-Unknown or
Not Available
cr~(1;~t~: #6L = = = = = = JD~
(MO~) [Locator
(Fir~
(M0032) Resumption of Care Date: o NA - Not Applic••a_b_le __
I
month day-
I
yea-;:(MI)
Patient Phone: _
~LQ __~~
/I
~~~
(MI)
Addre!tC~6Ptl
----------t":''=~''~~ K~ t lOS 1~1 V "'P-'-~~ _~ _ _ _ _ _~~~vt1~treeVAPtl~7013,-f5rv(J.ili~
patientfwress:J(LOcatg\\il6]
-
~WJ
~
-q- -
N:~d¥t
(SUffix)
_~ v}_ ~
4124)
~og _ _
_
(s;;tfix)-
Citya: (locator 1124)1
, EtlIV'S~O'()
_~O_
~atA:.5LOCatOr'#24)1
Zip Code: 'tlp~r
~O ~'"{~
_
_ _
(MI)
(City)
----
(M0050) Patient State of Residence: Uloc_al~6 ' (M0060) Patient Zip Code: [(lOcator116J] C?..1"- __
q
_
Secondary Referring Physician I.D.#: Phone: -
-
_
Name: _
_
_
_
_
_
(First) (Last)
(M0063)
____________
Medicare
Number:
0 NA - No Medicare
(including suffix)
(Suffix)
(M0140) Race/Ethnicity (as identified by patient): (Mark all that apply.) Cl 1 - American Indian or Alaska Native o 2 - Asian o 3 - Black or African-American "l$l 4 - Hispanic or Latino 5 - Native Hawaiian or Pacific Islander o 6 - White o UK - Unknown
o
(M0150) Current Payment Sources for Home Care: o 0 - None; no charge for current services 0 6 o 1 - Medicare (traditional fee-for-service) 0 7 o 2 - Medicare (HMO/managed care) 0 8 o 3 - Medicaid (traditional fee-for-service) 0 9 o 4 - Medicaid (HMO/managed care) 0 10 o 5 - Workers' compensation 0 11 o UK -
(Mark all that apply.) Title programs (e.g., Title III, V, or XX) Other government (e.g., CHAMPUS, VA, etc.) Private insurance Private HMO/managed care Self-pay Other (specify}, _ Unknown
!f·",J5!ieljJI
PT ORDERS: o Ultrasound ~Evaluation o~erapeutic Exercise 0 Electrotherapy 0 Prosthetic Training 't)1'#ansfer Training 0 Home Program Instruction o Muscle Re-education 0 Other: (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 - Eirly0 NA - Not Applicable: No.Medicare 2 - Later case mix group to be defined o UK - Unknown by this assessment ·Early Episode is first or second episode in a sequence of adjacent episodes, Later is the third episode and beyond in sequence of adjacent episodes. Adjacent episodes are separated by 60 days or fewer between episodes. ID#
(M0080) Discipline of Person Completing Assessment: o 1-RN \Xl 2-PT 0 3-SLP/ST 0 4-0T (M0090) Date Assessment (M0100) This Assessment Following Reason: Completed:
~
K
l..5j JoO 7
day year
is Currently
Being
Completed
for the
o o
StartfResum tion of Care - Start of care-further visits planned o 3 - Resumption of care (after inpatient stay) Certifica!i2n P~d: From _J_I_~ __
lfLl
(~cJ.~r 113) ., To (0 1 __
1 __
oq
1
Medical Record No. (if different than M0020): (locator #4)
PATIENT NAME-Lanrst,
a .au~--vw'2.-
Middle
In,,'
J()~
Page 1 of 16
92--31
PHYSICAL THERAPY ASSESSMENT
with OASIS ELEMENTS
Form 3495P-08
Rl007
© 2007 Briggs Medical Service Company (800) 247-2343 www.BriggsCorp.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.
,_.-
',-,-'
.-------
'-~'
,,---I
ID #
Patient Name
PATIENT HISTORY (Cont'd.)
Surgical Procedure
( ___
ICD-9-CM
~local.OLd2ll
o __
0
)
Date -_/ Date
__ /_/ /
/ __
OlE OlE /__
( PHYSICIAN: PRIMARY Date last contacted
)
Vu .e-i/l Q. ~
,
Date last visited __
REASON FOR HOME HEALTH:
PERTINENT
HISTORY AND/OR
~YP'rt'""'"
~"d'ao
o Infection 0 Immunosuppre o Other (specify) o Up to date IMMUNIZATIONS
PRIOR HOSPITALIZATIONS
t'b""
sed
PREVIOUS
OUTCOMES
(note dates of onset, exacerbation
when known) (site: )
U Respiratory 0 Osteoporosi 0 Open Wound 0 Surgeries
o Fractures o Cancer
o No
'1
Needs:
o Influenza
0 Pneumonia
o Tetanus o Other
<::
~s
(
Number of times
•
Reason(s)/Date(s):
c1o¥duv::
o - Guarded:
(S 5tJ~S
(M0250) Therapies
the patient receives at home: (Mark all that apply.) or infusion therapy(excludes ~ TPN)
:01- fntrav;;)ous
o2
m::J
(M0270) Rehabilitative prognosis for functional
Prognosis: status.
BEST description in functional
of patient's status is expected;
- Parenteral nutrition (TPN or lipids)
-
~
or any,
0 0
minimal improvement decline is possible
,0 3 - Enteral nutrition (nasogastric,
gastrostomy, iia.40;t0my, other artificial entry into the alimentary canal) •
1 - Good: marked improvement - Unknown
in functional
status is expected
o4
- None of the above
o UK o0o1-
(M0280) Life Expectancy: PROGNOSIS
(Physician documentation
is not reouired.)
(Locator #20)
Life expectancy Life expectancy
is greater than 6 months is 6 months or fewer
-
o 1-Poor
o 2-Guarded
o 3-Fair
o 4-Good
Q 5-Excellent
(M0260) Overall Prognosis: BEST description of patient's overall prognosis for recovery from this episode of illness.
ADVANCE
DIRECTIVES
0 0
o - Poor:
little or no recovery imminent
is expected
and/or further decline is
1 - Good/Fair: - Unknown
partial to full recovery is expected
o Living will o Do not resuscitate o Organ donor
Comments
o Education needed o Copies on file o Funeral arrangements
made
o UK
LIVING ARRANGEMENTS/SUPPORTIVE
(M0290) High Risk Factors characterizing this patient: (Mark all that apply.) (M9340) Patient
ASSISTANCE
Lives With: (Mark all that apply.) other
o o
1 - Heavy smoking 2 - Obesity 3 - Alcohol dependency Residence:
0 .~
4 - Drug dependency 5 - None of the above
d
1 - Lives alone With spouse or significant 3 - With other family member 4 - With a friend 5 - With paid help (other than home care agency staff) 6 - With other than above Other than Home Care Agency Staff:
o
0 UK - Unknown
(M0300) Current
i4
o o
o
_
! ~
-
\:l fI - Patient's
r
owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other) residence
o
2 - Family member's
o
o o
3 - Boarding home or rented room 4 - Board and care or assisted living facility 5 - Other (specify)
(M0350) Assisting Person(s) (Mark all that apply.)
, 0 . 1 - Relatives, friends, or neighbors
living outside the home
.;0 - 3 - Paid help
o o
UK - Unknown
2 - Person residing in the home (EXCLUDING paid help) go to M0390]
4 - None of the above [If None of the above, [If Unknown, go to M0390]
Name of facility Phone
Form 3495P-08
_ _
© 2007 Briggs Medical Service Company
is the intellectual
(800) 247-2343 www.BriggsCorp.com. The Outcome and ASsessment Information Set (OASIS) property of the Center for Health Services and Policy Research, Denver, Colorado. It is used with permission.
PHYSICAL THERAPY ASSESSMENT
with OASIS ELEMENTS
Page 3 of 16
-~-'
.-----
---PAIN o o
Never
-"--..-
'---.....--
Patient Name========================================
ID
#~=============-
Intensity:
(using scales below) Wong-Baker FACES Pain Rating Scale
How often is breakthrough medication needed? 0 Less than daily 0 2-3 times/day
($)'"'<:»
I o
No Pain @:!)
~~
NO HURT
~'d
HURTS LITTLE BIT
~@@ \C) VY \5J
HURTS EVEN MORE HURTS WHOLE LOT HURTS WORSE
More than 3 times/day [lain control medications adequate _ 0 Yes 0 No
o Current o Other:
HURTS LITTLE MORE
Implications Care Plan:
I
I
2
I
I
4
I
Moderate Pain
I
6
I
I
8 10 Worst Possible Pain
ENDOCRINE/HEMATOLOGY
o No
(Circle all applicable items)
Problem
--From Wong D.L., Hockenberry-Eaton M., Wilson D., Winkelstein M.L., Schwartz P: Wong's Essentials of Pediatric Nursing, ed. 6, S1.Louis, 200t, p. 1301 Copyrighted by Mosby, Inc. Reprinted by permission.
o
Diabetes: Type I Juvenile/Type Onset of diabetes
II _ _ _ On insulin since _
Collected using:
0 FACES Scale
00-10 Scale (subjective reporting)
o
Is patient experiencing Non-verbals demonstrated:
No Problem 0 No 0 Unable to communicate 0 Grimacing 0 Anger signs _
o Diet/Oral control (specify) o Insulin dose/frequency (specify)
o
Hyperglycemia: Glycosuria/ Polyuria/ Polydipsia Hypoglycemia: Sweats/ Polyphagia/Weak/ Faint! Stupor 0 Patient/Caregiver 0 Nurse 0 Other
pain? ~es
0 Diaphoresis
o Moaning/Crying 0 Guarding 0 Irritability o Tense 0 Restlessness 0 Change in vital
o
Other: 0 Implications:
o
o
_
Blood sugar ranges Monitored by: 0 Self 0 Caregiver Frequency of monitoring Competency with use of Glucometer
Report _ _ _
o Self-assessment
o
Pain Assessment Location Onset Present level (0-10)
Any diagnosed manifestations
(renal, ophthalmic,
neurologic, other)
Site 1
Site 2
Site 3
tBP
I G!tw-OV\\.(..
o
Disease
Management
Problems
(explain)
_
I tfl D
-
Worst pain gets (0-10) I Best pain gets (0-10) Pain description (aching, radiating, throbbing, etc.)
i()
o Enlarged
o Other
o o
thyroid
0 Fatigue
0 Intolerance to heat! cold _ _ 0 Hemophilia _
Anemia (specify if known) Secondary bleed: GI/GU/GYN/unknown OOther
(M0420) Frequency of Pain interfering with patient's activity or movement:
o0
o
- Patient has no pain or pain does not interfere with activity or movement _
INTEGUMENTARY
STATUS
1 - Less often than daily Turgor: Good / Poor
o No
Problem
Q 2 - Daily, but not constantly
Circle all applicable conditions listed below: Edema (specify if not otherwise in assessment):
b 3 - All of the..!!m~IiI:I-(M0430) Intractable Pain: Is the patient experiencing pain that is not easily relieved, occurs at least daily, and affects the patient's sleep, appetite, physical or emotional energy, concentration, personal relationships, emotions, or ability or desire to perform physical activity? ("No Frequency: 01 - Yes 0 Continuous 0 Intermittent _ 0 Movement 0 Ambulation 0 Immobility _ 0 Heat/Ice 0 Massage 0 Diversion _ 0 Repositioning
Itch / Rash / Dry / Scaling / Redness /Bruises / Ecchymosis / Pallor / Jaundice Other (specify) _
0 Occasionally
o Other:
What makes pain worse?
(M0440) Does this patient have a Skin Lesion or an Open Wound? ~~xcludes "OSTOMIES." ~"IQ0 [If No, go to M0490] 0 1 - Yes
o Other:
What makes pain better?
o
Rest/Relaxation
0 Medication
o Other:
Form 3495P-08
is the intellectual property
© 2007BriggsMedicalServiceCompany(800)247-2343 www.BriggsCorp.com. TheOutcome andASsessment tnlormation (OASIS) Set
ot
the Cenler tor Health Services and Policy Research,
Denver. Colorado. II is used with permission.
Page 5 of 16
PHYSICAL THERAPY ASSESSMENT
with OASIS ELEMENTS
---.--'
.~-(Observable) Pressure
-.---.,.-
-"-
'--
p
P.....1..:.
o NA
(M0460) Stage of Most Problematic Stage 1 ~ o 2 - Stage 21!!§I!) 3-Stage3~ Stage..41!!§I!)
Ulcer:
Ei 1-
- No observable pressure ulcer (Observable) Pressure Ulcer: DEFINITION: (M0464, M0468, M0470, M0474, M0476) WOCN Guidance
(M0464) Status of Most Problematic 1 - Fully granulating o 2 - Early/partial granulation o 3 - Not healing NA - No observable pressure ulcer
o
o
o0
(M0468) Does this patient have a Stasis Ulcer? - No [If No, go to M0482] 0 1 - Yes Number of Observable 0 3 - Three 0 4 - Four or more Stasis Ulcer(s):
1. Fully Granulating: Wound bed filled with granulation tissue to the level of the surrounding skin or new epithelium; no dead space, no avascular tissue (eschar and/or slough); no signs or symptoms of infection; wound edges are open. 2. Early/Partial Granulation: Greater than or equal to bed is covered with granulation tissue; there is tissue (eschar and/or slough) (i.e., less than 25% is covered with avascular tissue); may have dead symptoms of infection; wound edges open. 25% of the wound minimal avascular of the wound bed space; no signs or
(M0470) Current o 0 - Zero o 1 - One 02 - Two
(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a non removable dressing? 00No 01 -Yes (Observable) Stasis Ulcer: 3 - Not healine:m:,J 0 NA - No observable stasis ulcer (M0476) Status of Most Problematic o 1.:..Fully granulating _ o 2 - Early/partial granulation
m!I
ro-
3. Non-healing: Wound with greater than or equal to 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. Note: A new Stage I pressure ulcer is reported on OASIS as not healing.
(M0482) Does this patient have a Surgical
Wound?
DEFINITION:
o0
01
- No (If No, go to M0490) - Yes
(M0482, M0484, M0486, M0488) WOCN Guidance
(M0484) Current Number of (Observable) Surgical Wounds: (If a wound is partially closed but has more than one opening, consider each opening as a separate wound.) 00 - Zero 01 02 03 - One - Two - Three - Four or more
Description!classification of wounds healing by primary intention (i.e., approximated incisions) • Fully granulating/healing: Incision well-approximated with complete epithelialization of incision; no signs or symptoms of infection. • Early/partial granulation: Incision well-approximated but not completely epithelialized; no signs or symptoms of infection. • Non-healing: Incisional separation OR incisional necrosis OR signs or symptoms of infection. Description/classification of wounds healing by secondary intention (i.e., healing of dehisced wound by granulation, contraction and epithelialization) • Fully granulating: Wound bed filled with granulation tissue to the level of the surrounding skin or new epithelium; no dead space, no avascular tissue (eschar and/or slough); no signs or symptoms of infection; wound edges are open. • Early/Partial Granulation: Greater than or equal to 25% of the wound bed is covered with granulation tissue; there is minimal avascular tissue (eschar and/or slough) (i.e., less than 25% of the wound bed is covered with avascular tissue); may have dead space; no signs or symptoms of infection; wound edges open. • Non-healing: Wound with greater than or equal to 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 comprehensive appropriate wound management. _ 0 Sterile 0 Clean _ _ _ ~
o4
(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a non removable dressing? 00No 01 - Yes (M0488) Status of Most Problematic 1 - Fully granulating 02 - Early/partialgranulation ~ (Observable) Surgical Wound:
o
o
o NA
~.;.Not healing .~ - No observable surgical wound
Wound care done:
0 Yes
0 No By:
Location(s) if patient has more than one wound site: 0 Patient 0 Family!caregiver 0 RN/PT Technique:
o Soiled
dressing removed
o Wound o Wound
o
cleaned with (specify): irrigated with (specify):
Wound packed with (specify):
0~unddffis~ngap~~d~pec~0:
o Patient
tolerated
procedure
well
o Other
(specify):_~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ return demo: 0 Yes 0 No Education: 0 Yes
Satisfactory
Form 3495P·06
© 2007 Briggs Medical Service Company
is the intellectual
(800) 247-2343 www.BriggsCorp.com. The Outcome and ASsessment Information Set (OASIS) property of the Center for Health Services and Policy Research, Denver, Colorado. It is used with permission.
Page 7 of 16
PHYSICAL THERAPY ASSESSMENT
with OASIS ELEMENTS
.•.
-.
.•...•
''--.../
.~.--
.--.....ID #
Patient Name
o No
(Circle all applicable items)
•
Problem
".
ABDOMEN
(M1!.540) Bowel Incontinence
(Cont'd.)
Frequency:
9 - Very
0 Hesitancy 0 Nocturia
_ _ specify: _ _ _
rarely or never has bowel incontinence _
o
Urgency/frequency
0 Burning/pain
(when occurs)
o Hematuria
o
0 Oliguria/anuria
1 - Less than once weekly 2 - One to three times weekly
Urinary incontinence
3 - Four to six times weekly
4 - On a daily basis
o Diapers/other:
Urinary Catheter: Type (Foley/condom) Who's managing?
m:J
E
,0 _5 -=-Mo~ften
o
thaQ2.n~ d?Tiy NA - Patient has ostomy for bowel elimination Unknown
-:m:::J
o UK -
o Urostomy
site (describe skin around stoma):
(M0510) Has this patient been treated for a Urinary Tract Infection the past 14 days? ~No 1 - Yes
in
(M0550) 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, ill b) necessitated a change in medical or treatment regimen? o 0 - Patient does not have an ostomy for bowel elimination. CT1 - Patient's ostomy was not related to~anrr)p'aHenTStay and didnof necessitate change in medical or treatment regimen. 0-2.:. The ostomy was related to an inpatient stay or did necessitate change in_medical or tre?tment regimen-,-
I!El!J
W!1
ci
GENITALIA
treatment
o
NA - Patient on prophylactic
o No
o Breast
self-exam. RIL exam frequency Presence: or ostomy for
Problem 0 Discharge: R/L _ _ _
o UK o0
~-
- Unknown
or Urinary Catheter anuria
(M0520) Urinary Incontinence
o
Mastectomy:
Date __
I__
I__
- No incontinence or catheter (includes urinary drainage) [If No, go to M0540]
o Self-testicular
o o
Frequency
r::f2'-
Patient is incontinent Patient requires a urinary catheter (Le., external, intermittent, suprapubic) [Go to M0540] occor? defers incontinence
Lumps 0 Masses 0 BPH Other (specify, incl. history) Management Problems (explain)
indwelling,
(M0530) When does Urinary Incontinence
o Disease
o 0 - Timed-voiding
o 1 - During
the night only
- During the day and night
o No
o
Flatulence
Problel1:! 0 Diarrhea
0 Constipation/impaction
o
Rcctal blooding 0 Hcrnorrhotdc
n
I
""t RM
_
(M0560) Cognitive Functioning: __Patient's current level of alertness, ( orientation, comprehension, concentration, and immediate memory for simple commands.)
_
o
o
Frequency of stools Bowel regime/program: Laxative/Enema OOther: use:
AIOrtlOriont"d' "hi" tn fnr.I!" and shift attention. and recalls task directions independently, _ ~ 1 - Requires prompting (cuing, repetition, stressful or unfamiliar conditions, reminders)
comprehends only under
0 Daily
0 Weekly
0 Monthly
_ _ _
o o o
o Incontinence (details o Diapers/other: o Ileostomy/colostomy
if applicable)
2 - Requires assistance and some direction in specific situations (e.q. on all tasks involving shifting of attention), or consistently requires low stimulus environment due to distractibility, 3 - Requires considerable assistance alert and oriented or is unable directions more than half the time, in routine situations, Is not to shift attention and recall
site (describe skin around stoma):
_
4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium,
Ostomy care managed by:
0 Self
0 Caregiver site (describe skin around stoma): (locator 1119) o 1- Oriented
MENTAL STATUS
o
Other
o Disease
Management
Problems (explain)
_
o 2o 3-
Comatose Forgetful Depressed
o5o6-
Disoriented Lethargic
0 8 - Other
_
o 7 - Agitated
(Reported or Observed):
o 4ABDOMEN
Co -Never
o
0 Soft 0 Ascites
inches _
(M0570) When Confused
o No
o Tenderness
0 Pain
girth
Problem
0 Distention
0 Hard
o
o o
o Abdominal o Other:
Form 3495P-08
1 - In new or complex situations only 2 - On awakening or at night only 3 - During the day and evening, but not constantly 4 - Constantly - Patient nonresponsive
o NA
© 2007 Briggs Medical ervice S Company(BOO)247 -2343 www.BriggsCorp.com. TheOutcome andASsessment Informationet(OASIS) S is the intellectual property of the Center for Health Services and Policy Research, Denver, Co/ora do. It is used with permission.
PHYSICAL
THERAPY
Page 9 of 16
ASSESSMENT
with OASIS ELEMENTS
'---- -
'-.------
,,---.
."'--~.
'-..-ID #~======================_
PatientName~================================================~========================
FUNCTIONAL LIMITATIONS
(locator 18A) # o 1-Amputation
ADLlIADLs
(Cont'd.)
grooming
o 2-Bowel/Bladder
(Incontinence)
o 3-Contracture
o 4-Hearing
o 7-Ambulation o 8-Speech o 9-Legally blind
(M0670) Bathing: Ability to wash entire body. Excludes (washing face and hands only). rior urrent
o
~ _
0 - Able to bathe self in shower or tub independently.
1 - With the use of devices, is able to bathe self in shower or tub independently. 2 - Able to batheinshower or tu another person: 1m (a) for intermittent supervision reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas. - Participates in bathing self in shower or tub, requires presence of another person throughout bath for assistance or supervision.
o A-Dyspnea
DB-Other
with minimal exertion (specify)
o
0
o 5-Paralysis
o 6-Endurance
(locator 188) # o 1-Complete bedrest
o 15
________
0 NO LIMITATIONS
ACTIVITIES PERMITTED
o 2-BedrestlBRP o 3-Up as tolerated o 4-Transfer bed/chair o 5-Exercises prescribed o 6-Partial weight bearing o 7-Independent in home
o 8-Crutches o 9-Cane o A-Wheelchair o B-Walker o C-No restrictions o D-Other (specify)
0
1,-0 ..• .0 C~t
m::J
but the
0
4-- Unable to use the shower or-tub and is bat~'or bedside chair. m!J
I
I
0 0
5~~ Unable to effectively partiCiPate in bathin~gand is totall:t,
bathed by ~np,t!lerperso!l.1m UK - Unknown Ability to get to and from the toilet or bedside
ADLlIADLs
For M0640 - M0800, complete the "Current" column for all patients. For these same items, complete the "Prior" column only at start of care and at resumption of care; mark the level that corresponds to the patient's condition 14 days prior to start of care date (M0030) or resumption of care date (M0032). In all cases, record what the patient is able to do. (M0640) Grooming: Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or make-up, teeth or denture care, fingernail care). Prior. ~ur nt "ll - Able to groom self unaided, with or without the use of assistive devices or adapted methods. . 0 0 1 - Grooming utensils must be placed within reach before able to complete grooming activities. 2 - Someone must assist the patient to groom self. o o
/l
o o o
(M0680) Toileting: commode.
o - Able
to get to and from the toilet independently or without a device.
with
0
1 - When reminded, assisted, or supervised person, able to get to and from the toilet.
by another
2 - Unable to get to and from the toilet but is '8bletouSea bedside commode (with or without assistance). 1m_ to get to and from the toilet or bedside l commode but is able to use a b~pan/urinal ~_ .•..•.•• .J independently. o ...;!; - I~ totally, dependent in toileting:m:J!
q
3
= Unable
70 [}
o o
o o
m:JI ~~_
UK - Unknown -
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
o
3 - Patient depends grooming needs. UK - Unknown
entirely
upon
someone
else for
VC/SBA MIN MOD MAX- D
. Task
I 'Comments/Assist
I
Device
I I
Clothing Management ToiletHygiene Toileting Assessment:
(M0650) Ability to Dress .!mmrr Body (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps: ~,current
0-
o
~
o
0ir=;i'''o
o
'0
to get clothes out of closets and drawers, put Current level: them on and remove them from the upper body Without . . assistance. 1:; Able to dressupper body without assistanceif CiQ!b!1lg~r.' (M0690) Transferring: Ability to move from bed to chair, on and off toilet or commode, into and out of tubor shower, and ability to turn and is laid out or handed to the patient. position self in bed if patient is bedfast. Sorp.eone must help the gati§n!..,put on"]ppe[Q2dY ~ Current clothing. ~ 0 0 - Able to independently transfer. 3: Patient dependsentlrely another pe[~ii"tg)jLe~s the~uQP~bQd)l, o ~ 1 - Transfers with minimal human assistance or with use UK - Unknown of an assistive device.
o - Able
I
Previous level:
_
I
m:!J
1m
m:!I
uPQn-
(M0660) Ability to Dress Lower Body (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes: !!tiM,Current o o - Able to obtain, put on, and remove clothing and shoes without assistance. o ~ ~. ,..,~.- Able to dress"iowerbodYWithOUt' assistance lfCfotfiing ..... 'R~(~'-:- shoes are laid out or handed to the patient. and 2 o 'd~~. - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes. o ·0 3 - Patient depends entirely, upon another person to dress lower bo.9y" UK - Unknown o
o
0 0
2 - Unable to transfer self but is able to b~r pivot during the transfer process.
1m
ji§!.gi1tand
o
o o
3 - Unable to transfer self and is unable to bear we1Qhr or pivot when transferred by another person.
1m
0 ····4 - Bedfast, unable to transfer but is able to turn
position self in bed. m:J
anef
1m
0
1m
5'- Bedfast, unable to transfer and IS unable ,position self.
m::I-
-
to turn and~
m!J
o
UK - Unknown
FDrm 3495P-08
© 2007 Briggs Medical Service Company (800) 247-2343 www.BriggsCorp.com. The Outcome and ASsessment Inlormation Set (OASIS) is the intellectual property 01 the Center for Health Services and Policy Research, Denver. Colorado. It is used wilh permission.
Page 11 of 16
PHYSICAL THERAPY ASSESSMENT
with OASIS ELEMENTS
'.•.•.
----'
'
..••......--.
...
--.-- ..
''--..--.,
"---- ..
(M0720) Planning and Preparing or reheat delivered meals: Prior Current
Light Meals (e.g., cereal, sandwich)
(M0760) Shopping: Ability to plan for, select, and a store and to carry them home or arrange delivery. Prior Current
¥do
/
o-
(a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission)
D
D
D
J\
'"{'-J
1 - Unable to prepare light meals on a regular basis due to physical, cognitive, or mental limitations. 2 - Unable to prepare any light meals or reheat any delivered meals.
"-£" r--D ~
0 - (a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages; OR (b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission). 1 - Able to go shopping, but needs some assistance. (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping; OR (b) Unable to go shopping alone, but can go with someone to assist. 2 - Unable to go shopping, but is able to identify items needed, place orders, and arrange home delivery.
D
o
D
D
UK - Unknown
(M0730) Transportation: Physical and mental ability to safely use a car, taxi, or public transportation (bus, train, subway). Prior Current
D D
D
3 - Needs someone to do all shopping and errands. UK - Unknown
D
D
o - Able
to independently drive a regular or adapted car; OR uses a regular or handicap-accessible public bus.
~~
D
D
1 - Able to ride in a car only when driven by another person; OR able to use a bus or handicap van only when assisted or accompanied by another person.
(M0770) Ability to Use Telephone: Ability to answer the phone, dial numbers, and effectively use the telephone to communicate. rillt""'&urrent
o - Able
D
D D D D D D
D
2 - Unable to ride in a car, taxi, bus, or van, and requires transportation by ambulance. UK - Unknown
to dial numbers and answer calls appropriately and as desired.
D
D D D D D
1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers. 2 - Able to answer the telephone and carryon a normal conversation but has difficulty with placing calls. 3 - Able to answer the telephone only some of the time or is able to carryon only a limited conversation. 4 - Unable to answer the telephone at all but can listen if assisted with equipment. 5 - Totally unable to use the telephone. NA - Patient does not have a telephone. UK - Unknown
(M0740) Laundry: Ability to do own laundry - to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand. Prior Current
~D
o - (a) Able to independently
take care of all laundry tasks; OR (b) Physically, cognitively, and mentally able to do laundry and access facilities, but has not routinely performed laundry tasks in the past (i.e., prior to this home care admission).
D
D
D
\}>
~
_.
1 - Able to do only light laundry, such as minor hand wash or light washer loads. Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry such as carrying large loads of laundry. 2 - Unable to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation. UK - Unknown
D
y
D
(M0750) Housekeeping: Ability to safely and effectively perform light housekeeping and heavier cleaning tasks.
C"~"t
o - (a) Able
to independently perform all housekeeping~' tasks; OR (b) Physically, cognitively, and mentally able to perform all housekeeping tasks but has not routinely participated in housekeeping tasks in the past (i.e., prior to this home care admission).
D D
D D ~
1 - Able to perform only !igb1 housekeeping (e.g., dusting, wiping kitchen counters) tasks independently. 2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person. 3 - Unable to consistently perform any housekeeping tasks unless assisted by another person throughout the process. 4 - Unable to effectively participate in any housekeeping tasks. UK - Unknown
t
D
(M0780) Management of Oral Medications: Patient's ability to prepare and take all prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. Excludes injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness.) Current riOr ~ D 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 another person; OR (b) given daily reminders; OR (c) someone develops a drug diary or chart. 2 - Unable to take someone else. UK - Unknown Financial ability to pay for medications: medication unless administered by
D
D
D
D D
D
D
by
D
NA - No oral medications prescribed.
0 Yes
0 No
Form 349SP-08 © 2007 Briggs Medical Service Company
(800)247-2343 www.BriggsCorp.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.
PHYSICAL THERAPY ASSESSMENT
with OASIS ELEMENTS
Page 13 of 16
-,
--
.'
-,
---~.
----...--
.-------
'--.-.---
HOME ENVIRONMENT
, Oxygen use:
SAFETY (Cont'd.) OY safely 0 Knows how to use _ ON
(Include home safety, gait training, therapeutic management, electrotherapy, etc.)
exercise, wound
Signs posted Handles smoking/flammables Oxygen back-up: 0 Available safety
OY
ON
o Electrical/fire Comments:
Instructions/Materials
Provided
(Check all applicable
items)
o Rights and responsibilities o State hotline number
o Advance
o Do
o
directives (DNR)
not resuscitate
HIPAA Notice of Privacy Practices disrupted LJ-Needs assistance ")(Requires
o OASIS Privacy Notice o Emergency planning in the event service is o Agency phone number/after hours number o When to contact physician and/or agency o Standard precautions/handwashing
Basic home safety [J Disease (specify)
HOMEBOUND
assistance to ambulate
REASON
weakness
for all activities ~esidual
o
_ _
Confusion,
unable to go out of home alone
o
')@" Unable to safely leave home unassisted
o
o
Medication Other
regime/ administration
o o
o
Severe SOB, SOB upon exertion Dependent upon adaptive device(s) Other (specify)
0 Medical restrictions _
DME SUPPLIES
ll0~~)
WOUND CARE: IV SUPPLIES: URINARY/OSTOMY: DIABETIC: SUPPLIES/ EQUIPMENT:
o IV start kit
o IV pole o IV tubing
o
o 2x2's
4x4's OABD's o Cotton tipped applicators o Wound cleanser [j Wound gel o Drain sponges o Gloves: o Sterile 0 Non-sterile o Hydrocolloids o Kerlix size _ o Nu-gauze [j Saline o Tape o Transparent dressings o Other _
[j
o o
o
_
o Alcohol swabs o Angiocatheter size
o Tape o Extension tubings o Injection caps o Central line dressing
Underpads External catheters Urinary bag/pouch Ostomy pouch (brand, size)
o Chemstrips
.0 Syringes
o Other
_
o Bathbench o Cane o Commode o Special mattress overlay
o
Pressure relieving device
o Ostomy wafer (brand, size)
o Stoma adhesive tape
o Skin protect ant o Other
_ _ _
FOLEY SUPPLIES:
o Infusion pump o Batteries size
_
o Eggcrate o Hospital bed
MISCELLANEOUS:
o
Hoyer lift
o Syringes size
o Other
Fr catheter kit (tray, bag, foley) o Straight catheter o Irrigation tray o Saline o Acetic acid o Other
o __
Enema supplies o Feeding tube: type size o Suture removal kit o Staple removal kit o Steri strips o Other _
o
o Enteral feeding pump o Nebulizer o Oxygen concentrator o Suction machine
o Ventilator o Walker
_
o Wheelchair o Other
o Tens unit
_
o Medication o Potential o Duplicate
adverse effects/drug drug therapy
regimen comQletedlreviewed
(Locator #10)
0 Significant side effects 0 Significant drug interactions
Check if any of the following were identified: reactions 0 Ineffective drug therapy with drug therapy
0 Non-compliance
CARE COORDINATION:
0 Physician
0 SN 0 PT 0 OT 0 ST
Collaboration
Form 3495P-08
with patient on Plan of Care:
© 2007 Briggs Medical Service Company'
is the intellectual
es
0 No
(800) 247-2343 www.BriggsCorp.com. The Outcome and ASsessment Information Set (OASIS) property of the Center for Health Services and Policy Research, Denver, Colorado. It is used with permission.
PHYSICAL THERAPY ASSESSMENT
with OASIS ELEMENTS
Page 15 of 16
OMB Approval No. 0938-0910
Dynamic Home Care
14260 Ventura Boulevard, # 301 Sherman Oaks, California 91423 800.955.9111 NOTICE OF MEDICARE NON-COVERAGE
Date:
?:... -5'-- 0 ,7
Dynamic Home Care
Patient Name: Health Plan: Patient ID Number:
(~
Provider/Facility:
au cht:-7-- dL)jC H ciJ
~
Service Start!Admission Date: Attending Physician:
D1l
~ ~
S/0/
effl t2
21l-Y
c CJ
S
Address:
yt67J! ~~/
~S?/YJ
TIIE EFFECTIVE DATE COVERAGE OF YOUR CURRENT HOME HEALTH SERWCESWILL END ON: ".
t(,3{O;Z
-.
• •
Your Medicare Health plan and/or provider have determined that Medicare probably will not pay for your current HOME HEALTH SERVICES after the effective date indicated above. You may have to pay for any HOME HEALTH SERVICES you receive after the above date.
*
YOUR RIGHT TO APPEAL THIS DECISION
• • You have the right to an immediate, independent medical review (appeal), while your services continue, of the decision to end Medicare coverage of these services
I
If you choose to appeal, the independent reviewer will ask for your opinion. The reviewer will also look at your medical records and/or other relevant information. You do not have to prepare anything in writing, but you have the right to do so if you wish. ..' If you choose to appeal, you and the independent reviewer will each receive a copy of the detailed explanation about why your coverage for services should not continue. You will receive this detailed notice only after you request an appeal. If you choose to appeal, and the independent reviewer agrees that services should no longer be. covered after the effective date indicated above, neither Medicare nor your plan will pay for these services after that date. If you stop services no later than the effective date indicated above, you will avoid financial .liability .
•
•
•
HOW TO ASK FOR AN IMMEDIATE APPEAL
• You must make your request to your Quality Improvement Organization (also known as a QIO). A QIO is the independent reviewer authorized by Medicare to review the decision to end these services. ' . Your request for an immediate appeal should be made as soon as possible, but no later 1an noon of the day before the effective date indicated above. .
~J
• • •
The QIO will notify you of its decision as soon as possible, generally by no later than Je effective date of this notice. Call your QIO at: Lumetra at 1-800-841-1602 (TDD: 1-800-881-5980) to appeal, or if you have questions.
See next page of this notice for more information.
FORK #DHC-0033A
Page 1 of 2
PATIENT MEDICATION PROFILE
Dynamic Home (are
Primary Physician: Patient Allergies: Pharmacy Start Date
])u {jZa5
SOC/Recert Date:
(f-'0/0 9'
/7
!1dyV2 '--~,~'~---_--,-OI~~~~S0--'~lv~h~~S------~g~7~7 Sev\4"t 1?aq:=r1tH"U:tiLyPharmaCy Phone #: ~t 2) 519 go/xL) Name:
DIC
Medication
(Name, dose, route, frequency, duration)
Drug Classification
Date
Car
v
I fAl'O~UU i
I
lft-drlo
I-
•
io751Ylt1I..J
1::::.
YVl
q
Me. CJ(' 11N
S' rn V-U£JeJ. /\ L)S) n ofXh, , I
(; Lf}7JI u
~ ~ /VI.J? .-/
At)-y~U:1
u
S I)L)
--.-/
r1a
/&tvL0
DLq6t<1 V)
;~
S- M-:\
....Y
M/,
./
Co V fVl adc-V\tr
) YhdfwmlU(, ~ ocJrn __ F()..f'o~ tGc.- ~Y).L<
.s-:
Reviewed/Revised
By:
Reviewed/Revised
By:
Reviewed/Revised
By:
Patient Name:
DHC-006 03/03
C:::;" tJVJ/l ,"'VLe ~
Print last nde,
first name
~
1 <.J
~
Vf
MR#:
'~61
,
Dynamic
Home (are
PATIENT SAfETY REVIEW & EMERCENCV PLAN
[] [] [] [] [] [] [] []
[] [] [] [] [] [] []
Wheels on bed, wheelchairs, commode chairs, etc. should be locked when stationary. Electric beds should be kept in low position except during direct patient care. For a patient who has an electric bed, bed position hand control should be kept within reach of patient ifhe is allowed to adjust his own position. If a patient is bed bound, a bell buzzer or appropriate noisemaker should be kept in easy reach of the patient at all times. The bed bound patient has been instrocted to call for assistance when getting out of bed. If side rails are appropriate to the individual patient needs, the caregiver has been instrocted to keep these up at all times. A bell, buzzer, or appropriate noisemaker should be placed in the bathroom for emergency use for those who are ambulatory. Patients who live alone have been made aware of Emergency Call Systems, if these are available. Fire risks such as overloaded electrical circuits, frayed cords, open fireplaces, wood burning heaters, furniture, bedding in close contact with heat sources, oxygen usage in presence of open flame or cigarette smoking have been discussed and suggestions made for correction. Uneven floors, cluttered or poorly placed furniture, poor lightning and other risks which could lead to falls have been pointed out to family and suggestions made for correction. Any suspicion of patient abuse or neglect by caregivers should be brought to the immediate attention of the supervisor so a course of action can be planned. Family members have been instrocted never to leave patient alone in locked house unless a near neighbor or friend has access and is available if intervention is needed. Suggestions regarding escape routes in emergencies, and ramps for wheelchairs have been made. Emergency medical plans have been included in patient teaching. The home should contain smoke detectors in good working order. Rooms, toilet and bathroom facilities shall meet safety standards. Other _
EMERCENCY
PLAN
PHONE#: ~70 53,? PHONE #: -.3..[,0 21> \ ~ l ;; ~ PHONE#: PHONE#: 817 (f~9 63S-ii PHONE#: _
IN ANY DEAm-THREATENING SITUATION, CALL 911 FOR AMBULANCE, POLICE OR FIRE DEPARTMENT.
PS-fd(
Conditions to be reported to your home care nurse during office hours: (9:00a.m. to 6:00 p.m.) And/or to your physician:
1. 2. 3. 4. 5.
Difficulty in breathing. Temperature over 102 for more than 24 hours or a sustained time. Pain not relieved by medications already ordered by your physician. Active bleeding, nausea, vomiting, dizziness or change in patient's behavior and/or mental status. New onset of pain especially chest pain, jaw pain, arm pain or feeling of indigestion accompanied by sweating and nausea.
r
Remember, if a problem arises after office hours, call your physician or go to the emergency room at the hospital, nearest you. I have reviewed the above safety measures and emergency plan with the patient or responsible caregiver.
SNSignatf[re~
a
White: Chart
Date
J:~S'-O/
Canary: Patient
DHC-QOS 03103
Dynamic Home Care 14260 Ventura Blvd. Suite 301 Sherman Oaks, California 91423
PATIENT:
( ~
5) Ju ?C1AA
PATIENT ADMISSION AGREEMENT
/)os-:f
(Print Patient Last Name, First Name)
CONSENT FOR CARE: I hereby request admission to Dynamic Home Care and consent to the staff of said program to visit my home periodically to render home care services and/or provide home care supplies and/or equipment as ordered by my physician in a plan of care. The services to be provided to me by Dynamic Home Care staff have been explained to me. I understand the plan of care may change and that such changes will be discussed with me. FINANCIAL AGREEMENTS: I request direct payment to Dynamic Home Care of any Medicare, Medi-Cal, or other health insurance benefits otherwise payable to me for services rendered. I understand that should my health coverage fail to reimburse for services or supplies rendered that I acknowledge financial responsibility for payment/coinsurance/deductible amounts in accordance with my coverage. I have been given and understand the explanations given to me regarding my financial Obligation and the cost of services if my health insurance does not cover services rendered.
Medicare Number: Medi-Cal Number: Insurance Carrier: Eliaible for: Policy #:
r
1 Part A
r
1 Part B Group#:
Medi-Cal Issue Date:
RELEASE OF INFORMATION: I authorize information in my medical records to be released to representatives of Medicare, Medi-Cal, or other insurance carrier for use in determining home care benefits payable to Dynamic Home Care on my behalf. I authorize any hospital, nursing home, physician's office, other home care agency, supplier or other health facility where I have been a patient to disclose any part or all of my medical records to Dynamic Home Care. I also authorize the release of medical and other related information to social and/or health care agencies and medical equipment/supply vendors whose services may be required in conjunction with the services provided by Dynamic Home Care. I also authorize information in my medical records be made available to applicable surveyors during the reviews of the agency for compliance with regulatory, and/or other accreditation requirements. I consent to have information concerning my care electronically transmitted to government agencies via the internet and understand that confidentiality of information will be maintained at all times. I also acknowledge receipt of the "Privacy Act Statement" and "Statement of Patient Privacy Rights". CERTIFICATION: I certify that I have read and/or understand the above agreement, received a copy thereof, agree with the above conditions, and am the patient, or am a duly authorized representative of the patient legally authorized to execute the above and accept its terms. I understand that this agreement can be revoked at any time.
/
D
Relationship)
~ ~~,-O~
Date Signed Date Signed
DHC-002 03/03
White - Medical Record
Yellow - Patient
PATIENT ADMISSION AGREEMENT PATIENT:
SO-11 dtf/"l(Print Patient Last Name, First Name)
J O~
Page 2
PROPOSED PLAN OF SERVICES
o Skilled NursinQ(RN or LVN): o Certified Home Health Aide: o Social Worker:
CJ
~vsical Therapist: / o Occupational Therapist: o Speech Therapist: box(s) that indicate applicable liability)
POTENTIAL PAYMENT LIABILITIES: (check the appropriate
CJ
Medicare will cover the above-indicated services for the homebound patient at 100% as long as the services meet coverage guidelines including Part Time or Intermittent Nursing, PT, SLP, or OT services. The services of a Social Worker or Certified Home Health Aide may be then be covered, depending on the condition and needs of the patient. The patient is not responsible for any of these services even if Medicare subsequently disallows the services unless the patient or caregiver has falsified the information given to the agency. The above-indicated services are covered 100% by Medi-Cal [ 1 CCS [ 1 RIC [ 1 _ as long as the services are medically necessary and prior authorization is received from the case manager.
n
CJ
CJ
CJ
CJ
Your insurance carrier has informed us that the above services are covered by your private insurance at ____ % of the charges. Your liability for services, equipment and supplies is: _ The liability is to be paid, in full, within 15 days receipt of the invoice. You are responsible for 100% of charges for all services provided. Payment in full is due within 15 days receipt of the invoice. Medicare patients are responsible for deductibles and 20% co-insurance for Durable Medical Equipment and most patient care supplies. You may either ask us to arrange for delivery of these services or may make arrangements yourself. Charges will be discussed prior to delivery. You have the right to refuse to accept the recommended equipment or supplies. Medicare does not cover drugs and biologicals. You are responsible for purchase of these items.
CHARGES ARE: (list discioline
and rate oer hour or oer visit
ADVANCE DIRECTIVES: The undersigned has been given written materials about their right to accept or
refuse medical treatments; has been informed of their rights to formulate advance directives; understands that they are not required to have an advance directive in order to receive care by Dynamic Home Care; understands that the terms of any advance directive that they have executed will be followed by Dynamic Home Care and their caregivers to the extent permitted by law; and has been informed on how to get additional information. I have executed an advance directive. (Name of DPOA: _ o I have not executed an advance directive.
o
PATIENT RIGHTS AND RESPONSIBILITIES: The undersigned has received a copy of the Rights and Responsibilities document. I have been fully informed, and my questions have been answered. PATIENT COMPLAINTS: The undersigned has received information regarding the process to report patient
complaints and concerns.
"
(/)
Date Signed
Date Signed
I..4&:UAL
b..J:r: ')
~)
ct
c-
HL: ~
INSTRUCT
IN HOME SAFETY ROLL, SCOOT, BRIDGE
C;;;IL L.
t ~s
t.rt=.-~W l~
~\
X
f
BED MOBILITY: 1RANSFER
0
-:t:::)
$a CHAIR
0 SHOWER
WB
-S,) Y.) ~
't....
_~~~.L
~O
i-
~
TRAlNING:JitBED
00 WHEELCHAIR 0 COMMODE 0
X
o TOILET
l§Sl.IE'INelSIT GAIT TRAINING FOR:
lLslT/sTAND
0 TRUNK
CON/ROL (
0 PATIERN
o BALANCE 0 STRIDE 0 FOOT PLACEMENT 0 STAIRS o PROGRESSIVE WJ BEARING 0 PROGRESSIVE eQUIPMENT
I..,pJLEVEL SURFACE
® ~tt-~ ~~r.M ~) A-Mb ~
~\ttA-f)y~
-i,.,';j
.n"
JJ~ ~~
"(
FWW
I-tHA-Zf:.t ~t
;;;:-qpod
I
~
0
UNEVEN SURFACE
~ISTNE __
DEVICES MIN
L\n .••
L.l!-A-
-c:, PwW
01Jc
~o
c;
[:..
c.J
PAIN CONTROL:
00
UL1RASOUND@_o_FOR FOR __ MIN MIN MIN
o ELEC
STIM @ __
o WHIRLPOOL FOR __ o MOIST HEAT FOR __ o MASSAGE TO
BODY MECHANICS INSTRUCT TRAINING CAREoGIVER
o INSTRUCT MEDS o TENS INSTRUCT
HEAT FOR
0 DRY
--
MIN
OEDEMA
CONTROLIREDUC.
o NEW
Frequency and duration: _'_/wk for _1 _ wks, ~lwk for __ wks, __ Iwk for __ CJ May start P .T. services when approved by insurance case manager or IPA representative. o Elements of the Plan of Treatment may be assigned to a Physical Therapy Assistant. CJ Recommend referral to: 0 SN 0 CHHA DOT 0 ST 0 MSW Rehab potential is (l'zf9ood 0 fair 0 poor) for (t.2Hun Dpartial) return to prior level of functioning. Narrative summary "scribes patient's rehab potential; i.e. why is the patient a good P.T.candidate?
PLAN OF1REATMENT
0
CHANGE IN PLAN OF. TREATMENT
I
wks
It
-
$$Date M.D. notified af plan: Plan Established by:
Physician Signature:
DATE:
PATIENT NAME:
Date:
TIME OUT: , ~.)
MR#qz...g'f
Dynamic Home Cafe
.Clinical Report for Author'izatlon
Patient Name
S'Wvt~ ~
dOs,<:.
Pt# '11--f"f
Cert Period g.")".(jCf
totO,~';-OC:Z
Insurance Co : d.i~~, MedicaJ, Secure Horizon, BCBS, Health Net, SCAN, Pacificar ..HealthCare Partners', Other _
PREAUTH VISITS: Freq
'.' SN ST :... expires expires'
twI
, PT , MSW PT
'2. W\
expires, expires, OT
Anticipated DC Date'~ , "OT , HRA ·ST '. MSW expires'
.,.;-/~'O _
"l.»
_
expires HHA----'~
Additional Visits Needed: SN __ Reason for Additional auth
----------~------~------~
if yes whye~
Is Patient Homebound~O, Primary Diagnosis Secondary Diagnosis SurgicaJDiagnosis Addl Diagnosis ~
Syh.C~
.
avtkrllM.Ce. (
Soe;
1)L~JJ.y·
ICP-9
ICD-9 __ ICD~9_'
.'
W(&.,ki~r... '
C1
.
tJ,-of,(~
.' '7)(0·2
D#'4Jtf:,~
~!lJ
.
_ ---'_
ICD-9
Physicians PII:!D Treatment (check all that apply) You MUST attach separate form for "Woundcare of . Teach wound carel Administration of IV or injectable meds Teach GT feedings/Managernent Diabetic Education Blood sugar Testing Method: Patient is not teachable due to; Perform wound carel Administration of meds \' enipuncture for Labs Pain Mgmt: Where . Treatment Pain Level ( 0-10) Clinicallyunstable: Requires SN for assessment & education of illness/ disease process Medication Mgmt/ Chg in Medication List: Other:
Is there a Peg in the home YES, NO
-: ,
,
Are they teachable 'CP Assessment BP 'Pulse Chg in Condition
YES NO
Patient treatment (circle all that apply)
PICC line, IV antibiotics, Colostomy/Ileostomy
Indwelling Foley Catheter, PT/INR draws, Wound Vac
RN signa ur ~
.
f7
Date
8 -S'-o?
Supervisor Signature
~---Date
OTI-IER APPEAL RIGHTS:
• If you miss the deadline for requesting an immediate appeal with the QIO, you still may request an expedited appeal from your Medicare Health plan. If your request does not meet the criteria for an expedited review, your plan will review the decision under its rules for standard appeals. Please see your Evidence of Coverage for more information. Contact your plan or 1-800-MEDICARE (1-800-633-4227), or TTY: 1-877-486-2048 for more information about the appeals process.
•
ADDITIONAL INFORMATION (OPTIONAL)
For a Skilled Nursing Facility Stay Termination: The "Effective Date" shown on this notice is the last day your services are covered. The day that you leave, which is called the "date of discharge", is the day after the effective date. As long as you leave the facility the day after the "effective date" you will not have financial liability for any additional days.
*
Please sign below to indicate that you have received this notice.
I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my QIO.
~~S-~U7
Date
Form No. CMS-l0095 (NOMNC) Exp. Date: 8131/2010 According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0910. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. [fyou have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
eMS Regfon~IX Approved 12/07
Page 2 of2 FORK #0033B
Patient Name
ID
PROFESSIONAL
PT - FREQUENCY/DURATION ~Evaluation and Treatment '0 Pulse Oximetry PRN o Home Safety/Falls Prevention
SERVICES
#~================-
o Occupational
o
Therapy to evaluate and treat
Speech Therapy to evaluate and treat to evaluate and treat
o Nursing
o
'ff Therapeutic
Exercise ]:rTransfer Training ~ Gait Training o Establish Home Exercise Program o Modality (specify frequency, duration, amount)
U Medical Social Services to evaluate and treat
Aide to assume responsibility for personal care needs by
(date) _
Comments:
_
o o
Prosthetic Training Muscle Re-Education DOther
_
REHABILITATION
POTENTIAL I GOALS
o
o
~
Demonstrate effective pain management within Improve bed mobility to Improve bed mobility to independent
weeks. weeks. within weeks. weeks.
assist within within ~ weeks.
o
~
Improve transfers to assist using Independent with transfer skills within ~ weeks. Patient to be independent with safety issues in ~
o
o o
o
~
o
Improve wheelchair use to within weeks. Patient will ambulate with device with __ assist within weeks. Patient will be able to climb stairs/uneven surfaces with device with Independent with ambulation with t="Wlt/ device within '2- weeks. --Ambulation endurance will be minutes or ~ feet within ~ weeks. Increase strength of 0 R 0 L UE to __ Increase strength of 0 R 0 L LE to Improve strength of
assist within
weeks.
o o
o
l.~s
/5 in /5 in to ~~
weeks to allow patient to perform the following activity weeks to allow patient to perform the following activity /5 within ~ w~
_ _
to allow patient to perform the following activity
_-"~~(-'-f._~~ "'"'=~...'l(.2::) ....• ..• .•••... -~ ---------------------.LJ.~••
:m ...
o o
o o o
Increase ROM of joint to to allow patient to perform the following activity
degree flexion and
degree extension in
weeks _ _ _
Increase ROM of joint to degree of in weeks to allow patient to perform the following activity Demonstrate ROM to WNL within weeks to allow patient to perform the following activity Demonstrate proper use of prosthesis/brace/splint within Demonstrate proper use of DME within weeks. Patient will have an increase in Tinetti Balance score to Improve balance score to using level of function within Patient will meet maximum rehab potential within Return to optimal and safe functionality within weeks.
o
o
/28 within
test.
weeks.
')i'l Return to pre-injury/illness
-.3:::.
o
o o
weeks. weeks. weeks. . within . within weeks. weeks.
o
Other: Other:
DISCHARGE
~Return
PLANS
to an independent level of care (self-care)
o
o o
Medical condition stabilizes When maximum functional potential reached Discharge at the end of the episode if the patient is hospitalized _ _
)fAble to remain in residence with assistance of primary caregiver/support from community agencies
o o
When patient knowledgeable about when to notify physician Able to understand medication regime and care related to diagnoses WITH PATIENT:~ Yes 0 No REHAB POTENTIAL:
o Other
o
Other
DISCUSSED
o Poor
0 Fair
/
Form 3495P-OB
/_--
Date Transmitted
/
/
© 2007 Briggs Medical Service Company (800) 247-2343 www.BriggsCorp.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.
PHYSICAL THERAPY ASSESSMENT
with OASIS ELEMENTS
Page 16 of 16
PatientName~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
MEDICATIONS (Cont'd.)
(M0790) Management of Inhalant/Mist Medications: Patient's ability to prepare and take ill! prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. Excludes all other forms of medication (oral tablets, injectable and IV medications). ~.~urnl ~. 0 0 - Able to independently take the correct medication proper dosage at the correct times. 1 - Able to take medication at the correct times if: (a) individual dosages are prepared in advance another person; OR (b) given daily reminders. 2 - Unable to take someone else. NA - No inhalant/mist UK - Unknown medication medications unless prescribed. administered and
EQUIPMENT MANAGEMENT
10#==========================_ (Cont'd.)
(M0820) Caregiver Management of Equipment (includes ONLY oxygen, lV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies): Caregiver's ability to set up, monitor, and change equipment reliably and safely, add appropriate fluids or medication, clean/ store/dispose of equipment or supplies using proper technique. (NOTE: This refers to ability, not compliance or willingness.)
o o
0 - Caregiver manages independently.
all tasks related to equipment
completely
o
o
o
0
by
1 - If someone else sets up equipment, all other aspects.
caregiver is able to manage
o
by
0
2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.
o o o o
3 - Caregiver is only able to complete small portions of task (e.g.,
administer nebulizer ment or supplies). treatment, clean/store/dispose of equip-
0
o
(MOSOO) Management of Injectable Medications: Patient's ability to prepare and take ill! prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals. Excludes IV medications. Prior Current
4 - Caregiver is completely all equipment. NA - No caregiver UK - Unknown
dependent
on someone else to manage
THERAPY
0 - Able to independently
take the correct mooicationand proper dosage at the correct times. ~ (MOS26) 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 therapYvisit;Tndicated ~~~ti~nal and speech-language NA - Not applicable: (total of physioal.s pathologl;?0mbined).
o
LJ
o o
1 - Able to take injectable medication at correct times if: , (a) individual syringes are prepared in advance by:' another person; OR - - - - - - - -(b) given daily reminders. ~ 2 - Unable to take injectable medica"tions un!eSs admi"iiis~ered_by someone else. _ ~ NA - No injectable medications UK - Unknown prescribed.
o
o o
o
o
G!ll
o
No case mix group defined by this assessment.
Safety
Measures;
(locator#15)
o
(M0810) Patient Management of Equipment (includes ONLY oxygen, lV/infusion therapy, enteral/parenteral nutrition equipment or supplies): Patient's ability to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/ dispose of equipment or supplies using proper technique. (NOTE: This refers to ability, not compliance or willingness.)
1 - Bleeding precautions
o
o
0 - Patient manages
independently.
all tasks
related
to equipment
completely
o o o o o o
2 - O2 precautions 3 - Seizure precautions 4 - Fall precautions 5 - Aspiration precautions •• 6 - Siderails up
7 - Elevate .head of bed SAFETY
o o
o o
8 - 24 hr. supervision
o o
910 11 12 13 -
Clear pathways Lock W/c with transfers Infection control measures Walker/cane Other ---''--_
1 - If someone else sets up equipment (i.e., fills portable oxygen tank, provides patient with prepared solutions). patient is able to manage all other aspects of equipment.
HOME ENVIRONMENT Safety hazards
o
o o
in the home OY OY OY OY or outlets OY OY OY OY OY OY safety: OY on all levels of home OY ON ON ON ON ON ON ON ON ON ON ON ON
2 - Patient requires considerable
manage equipment, the task.
assistance from another person to but independently completes portions of
Unsound structure Inadequate Inadequate Inadequate heating/ cooling/ electricity sanitation/plumbing refrigeration appliances
3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment. 4 - Patient is completely equipment. NA - No equipment dependent on someone else to manage all
Unsafe gas/electrical Inadequate
o
of this type used in care. [If NA, Go
to M0826]
running water available and/or unable to use phone stored safely planning/fire
Unsafe storage of supplies/ equipment No telephone Medications Emergency Insects !rodents
Fire extinguisher Smoke detectors
Tested and functioning More than one exit Plan for exit Plan for power failure
OY
OY
ON
ON
OY
OY
ON
ON
Form
3495P-08
© 2007 Briggs Medical Service Company
is the intellectual
(BOO)247·2343 www.BriggsCorp.com. The Outcome and ASsessment Information Set (OASIS) property of the Center for Health Services and Policy Research, Denver, Colorado. It is used with permission.
PHYSICAL THERAPY
ASSESSMENT
with OASIS ELEMENTS
Page 14 of 16
Assess each factor and circle the score when "yes", then total the points.
Patient Factors Wheelchair Taile!, Tub/Shower Car I I
Score
15 5
I
u f JJc
I History
of falls (any in the past 3 months?) Sensory deficit (vision and/or hearing) , Age (over 65)
~
5 5 5 5
I Confusion I Impaired judgment
Decreased level of cooperation anxiety/emotional liability (needs to use ambulatory aide,
Bed Mobility: RolifTumI
~.. Transfer Assessment: Previous level:_---"C::'-O--"",..~;--::;__~-;-------------Current level: Sit/Supine Sit/Stand
I Increased
Unable to ambulate independently chairboard, etc.)
Gait/balance/coordination
(9
5 5
problems
Incontinence/urgency
Cbk -tv' WI'ZFunctional
Cardiovascular/respiratory oxygenation
disease affecting perfusion and/or
". I
Postural hypotension with dizziness Medications affecting blood pressure or level of consciousness (consider antihistamines, antihypertensives, antiseizure, benzodiazepines, cathartics, diuretics, hypoglycemics, narcotics, psychotropics, sedatives/hypnotics) Alcohol use Environmental Factors Home safety issues (lighting, pathway, cord, tubing, floor coverings, stairs, etc.) Lack of home modifications Implement fall precautions (bathroom, kitchen, stairs entries, etc.) for a total score of 15 or greater.
specific to areas of risk
I
o Appears
0 Additional Training Required
5
',(M0700) Ambulation/Locomotion: Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces. ri r Current -' 0 - Able to independently walk on even and uneven surfaces and climb stairs with or without railings (i.e., ~ needs no human assistance or assistive device) . IQ -,- - RequTres usii'Ot'a aevice(~.g" cane, walker)towalk ~"'--lalone ill requires human supervision or assistance..!ol j negotiate stairs or steps or uneven surfaces, o ~2 - Able to walk only with the supervi§ion or a$$istanfe '1__ '01 another person at all times. o ~,0 3.- Chairfast, unable to ambulate but is able to wheel self
5
5
..:J. .
l
Ii§l!I
As guided by organizational guidelines: 1. Educate on fall prevention strategies 3. Monitor 4. Reassess areas of risk to reduce falls patient
Total points:
I t5 I
5
2. Refer to Physical Therapy and/or Occupational Therapy
m!J . __ _ _
__
o
0
..
~_l
o
!.o
o
independently. 4 - Chairfast, unable to ambul~ anQ.ls unable to wheel self. ~a-::r.r.. 5. - B\';ldfasj"unat.>!e tCl"arnbut?te oLge upjn sLcl1alIL~ UK - Unknown
m:J'="'::r=="-=--" .:': .:
_ _ __ _
EVALUATION
APPLIANCES/SPECIAL o o o o o o
Brace/Orthotics Prosthesis: (specify) Board/Lift
EQUIPMENT
_
1m_ _
o Transfer
equipment:
0 Bedside commode _ _
RUE / RLE / LUE / LLE /Other
CURRENT FINDINGS/GAIT
Muscle Tone:----,;;;;;;r:--:;;-----:r-=---..,..------Posture: Endurance:
Grab bars: Bathroom / Other Hospital bed: Semi-elec./Crank/Spec. Lifeline Needs (spec!fy) None usee! Oxygen: HME Co, Phone providing service:
pO' P'Y'"
~'~~v
fa [~O
J
I A
~
f1>/1.(....f"
kr1-C o
o
baf1,.~
J
'f
tirab
T
t.
JJQ/
_ _ _ _
Gait Assessment:
Distance Assistance Assistive Device Quality/Deviations
Uneven Surfaces
Stairs
Other
HME Rep.
o Other
organizations
Comments:
ADL/IADLs rll-ttn1Mi1/ "
(Cant'd.)
Weight
Bearing
Status:
(specifyextremities)
_
WB 0 WBAT 0 PWB 0 TDWB SISTIVE DEVICE(S): alksr
0 Cane
Walker
0 NWB 0 Quad Cane
0 Hemi Walker
o Wheeled
0 Other ------------------
(M0710) Feeding or Eating: Ability to feed self meals and snacks. Note: This refers only to the process of eating, chewing, and swallowing, nbt preparing the food to be eaten. Prior~ ~ 9'" 0 - Able to independently feed self. o 0 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. o 0 2 - Unable to feed self and must be assisted or supervised throughout the meal/snack. o 0 3 - Able to take in nutrients orally and receives supplemental nutrients through a nasogastric tube or gastrostomy, o 0 4 - Unable to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy. o 0 5 - Unable to take in nutrients orally or by tube feeding. o UK - Unknown
Form 3495P-08
© 2007 Briggs Medical Service Company (800) 247·2343 www.BriggsCorp.com. The Oulcome and ASsessment InformationSet (OASIS) is the intellectual properly 01 the Center for Health Services and Policy Research, Denver,Colorado.It is used with permission.
Page 12 of 16
PHYSICAL THERAPY ASSESSMENT
with OASIS ELEMENTS
·-----.
--I
or Observed):
~-----.--
."-../
~
ID #::;;;:============;;::-
PatientName~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
MENTAL STATUS (Cont'd.)
(MOS80) When Anxious (Reported 0 - None of the time o 1 - Less often than daily o 2 - Daily, but not constantly o 3 - All of the time o NA - Patient nonresponsive
PRIOR LEVEL OF FUNCTION
In-Home Mobility (gait or wheelchair): Independent Assistive Devices Community
o
o
0 Needed Assistance Used:
(gait or wheelchair): 0 Needed Assistance Used:
0 Unable
_
Mobility
o Independent Assistive Devices
_ _ _ _
0 Unable _
Primary language ~anguage barrier
Q
flaMA.-..----------,
0 Needs interpreter
o
Fracture (Iocation) painful joints (specify) res: Joint ROM Location 0 Poor conditioning
_ _ _ _ _
o
o
Learning barrier: Mental/Psychosocial/Physical/Functional Unable to read/write Educational level implications that impact care. Spiritual resource Phone No.
o Swollen
o Contractu
o o
Atrophy
o Spiritual/Cultural
o Decreased o
0 Paresthesia
0 Weakness R/L (specify)
Shuffling/wide-based gait Amputation: BK/AK/UE; R/L
o Angry 0 Flat affect 0 Discouraged o Withdrawn 0 Difficulty coping 0 Disorganized o Depressed: Recent/Long term Treatment o Inability to cope with altered health status as evidenced by: o Lack of motivation 0 Inability to recognize problems o Unrealistic expectations 0 Denial of problems o Sleep/Rest: 0 Adequate 0 Inadequate
Explain
Dominant side: _
_
o Hemiplegia 0 Paraplegia 0 Quadriplegia o Headache: Location Frequency o Aphasia: Receptive/Expressive o Motor change: Fine/Gross o Weakness: UE/LE Location o Tremors: Fine/Gross/Paralysis o Stuporous/Hallucinations: Visual/Auditory
o
PERRLA Hand grips: 0 Unequal pupils: R / L Equal/Unequal, specify Strong/Weak, specify
_
_
o Inappropriate responses to caregivers/clinician o Inappropriate follow-through in past o Evidence of abuse/neglect/exploitation: 0 Potential o Other
_ _ _
0 Actual
o Verbal/Emotional
(specify)
0 Physical
0 Financial _ in Patient:
o Other
o
(specify, incl. history) Problems (explain)
(MOS90) Depressive Feelings Reported or Observed (Mark all that apply.) o 1 - Depressed mood (e.q., feeling sad, tearful) o 2 - Sense of failure or self reproach o 3 - Hopelessness o 4 - Recurrent thoughts of death o 5 - Thoughts of suicide SIl - None of the above feelings observed or reported
Disease Management
_
(M0610) Behaviors Demonstrated at Least Once a Week (Reported or Observed): (Mark all that apply.) o 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. o 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. o 4 - Physical aggression: agg~essive or combative to self and others (e.g., hits self, throws objects, punches, dangerous maneuvers with wheelchair or other objects). o 5 - Disruptive, infantile, or socially inappropriate behavior (excludes verbal actions). o 6 - Delusional, hallucinatory, or paranoid behavior. ~None of the above behaviors demonstrated.
Flex/Extend Abd.lAdd. Int. Rot.!Ext. Rot. Flex/Extend Sup.lPron. Flex/Extend Flex/Extend Flex/Extend Abd.lAdd. Int. Rot.!Ext. Rot. Flex/Extend Plant.!Dors. Inver.lEver.
o
AREA
MANUAL
GRADE I
STRENGTH
ACTION
ROM
(M0620) Frequency of Behavior Problems (Reported or Observed) (e.g., wandering episodes, self abuse, verbal disruption, physical ression, etc.): . 0 - Never 0 3 - Several times each month ~ 1 - Less than once a month 0 4 - Several times a week 0 5 - At least daily Nursing Services at
MUSCLE TEST (MMT) MUSCLE STRENGTH
DESCRIPTION
5 4 3 2 1
Normal functional strength· against qravity- full resistance. Good strength· against gravity with some resistance. Fair strength· against gravity· no resistance> saiety compromise. Poor strength· unable to move against gravity. Trace strength· slight muscle contraction· Zero· no active muscle contraction. no motion.
o 2 - Once
a month
(M0630) Is this patient receiving Psychiatric home provided by a qualified psychiatric nurse? o 0 - No 0 1 - Yes
Form 3495P·08
o
© 2007 Briggs Medical Service Company (800) 247·2343 www.BriggsCorp.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.
PHYSICAL THERAPY ASSESSMENT
with OASIS ELEMENTS
Page 10 of 16
----.--
,--,-
'-----
·.1~(M0490) When is the patient dyspneic or noticeably Short of Breath?
o0o1U No Problem
Never, patient is not short of breath When walking more than 20 feet, climbing stairs moderate exertion (e,g:- while dressing,using or bedpan, walking distances less than 20 feet) other ADLs) or with agitation 'Commode
02 - wTIhpolicy.
This section completed
in accordance
with organizational
W!) ---
(Circle all applicable items) Blood At rest With activity Post activity Temperature:. Pulse: 0 Apical_. __ ~adial _ Pressure: Standing
03 - With minimal exertion (e.q, while eating, talking, or performing
t!.4' :.;At L.5!st(durinqday
(M0500) Respiratory
or ~ightl
6m1
m:EI
-
-
o Assessed
Treatments
0 Reported
utilized at home: (Mark all that apply.)
o o
Oral
0 Axillary
o1o2Q
Oxygen (intermittent or continuous) Ventilator (continually or at night)
Rectal ~nic
3 - Continuous positive airway pressure
- None of the above
0 RegUI~
o4 o At
o At
Rest 0 Activity _ Rest
([0
Date
0 Regular/Irregular
Type
NUTRITIONAL
~Problem DNAS ONPO
STATUS
0 Other _ I
o
Pacemaker:
Respirations: Breath Sounds: 0 Clear (reason)
0 Regular/Irregular
0 Other
0 Activity
_ _
ted Sweets
o
Deferred
o Accessory
o Other:
muscles used
0 02
@
LPM per
_ _
o Inc~:_Q
Appetite:
am!-~~.~:.!!.~id~_
amt.-.I
0 Good
o Fair
"poor
0 Anorexic Amount. _
Does this patient have a trach? Who manages? 0 Self
0 Yes
0 No 0 RN _
o Nausea/Vomiting:
Frequency
0 Caregiver/family
o
Other
o
Heartburn (food intolerance) Gain/Loss lb. X wk./mo./yr. _
o Cough:
0 No
DYes: Describe:
o Weight change: OOther
0 Productive 0 Non-productive
_
Directions: Circle each area with "yes" to assessment, then total score to determine additional risk.
YES
2
o
Dyspnea: Comments:
0 Rest
0 During ADL's _
Has an illness or condition that changed the kind and/or amount of food eaten. Eats fewer than 2 meals per day. Eats few fruits, vegetables or milk products. Has 3 or more drinks of beer, liquor or wine almost every day. Has tooth or mouth problems that make it hard to eat. Does not always have enough money to buy the food needed. Eats alone most of the time. Takes 3 or more different prescribed or over-the-counter drugs a day. Without wanting to, has lost or gained 10 pounds in the last 6 months. Not always physically able to shop, cook and/or feed self. TOTAL I I I I I I
3 2 2 2 4 1 1
Positioning
necessary for improved breathing:
o No
DYes, describe: . _
o
Chest Pain:
0 Anginal 0 Dull with:
0 Postural
0 Localized
0 Substernal
2
2
o
Radiating
0 Ache
0 Sharp
0 Vise-like 0 Activity 0 Sweats _ _
Associated
0 Shortness of breath
Frequency/duration: How relieved:
Reprinted with permission by the Nutrition Screening Initiative, a project of the American Academy of Family Physicians, the American Dietetic Association and the National Council on the Aging, lnc., and funded in part by a grant from Ross Products Division, Abbott Laboratories Inc.
INTERPRETATION 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 situation and organization policy. 6 or more High risk. Coordinate with physician, dietitian, social service professional or nurse about how to improve nutritional health. Reassess nutritional status and educate based on plan of care. Describe at risk intervention: _
o
Palpitations 0 Pedal
0 Fatigue RighVLeft 0 Dependent: _
OEdema:
o Sacral
_
o Pitting o Cramps o Disease
+1/+2/+3/+4 0 Non-pitting site (specify), 0 Capillary refill less than 3 sec / more than 3 sec
Management Problems (explain)
_
Form
3495P-08
© 2007 Briggs Medical Service Company
is the intellectual
(800) 247-2343 www.BriggsCorp.com. The Outcome and ASsessment Information Set (OASIS) property of the Center for Health Services and Policy Research, Denver, Colorado. It is used with permission.
PHYSICAL THERAPY ASSESSMENT
with OASIS ELEMENTS
Page 8 of 16
--.-
~
10#
-,~.
Patient Name
INTEGUMENTARY
WOUND/LESION
(specify) Location Type: diabetic ulcer pressure ulcer venous stasis ulcer arterial ulcer traumatic wound burn wound surgical wound other (specify) Size (ern) (LxWxD) Stage (pressure ulcers only) Tunneling/ Undermining (ern) Odor Surrounding Skin Edema Stoma Appearance of the Wound Bed
STATUS (Cont'd.) .,
Drainage/Amount
Color
o None o Smail o Moderate o Large o Clear o Tan o Serosanguineous o Other
OThin o Thick
o Small o Moderate o Large
U None
o None o Smail o Moderate
[J
Large
o Clear
o Serosanguineous o Other
OThin
o Tan
o Clear o Serosanguineous lJ Other
o Thick
D 1 - Yes
o Tan
o None o Smail o Moderate o Large o Clear o Tan o Serosanguineous o Other
OThin [] Thick
o None o Smail o Moderate o Large
o
o Tan o Serosanguineous o Other o Thick
o Thin
Clear
Consistency
o Thick
o Thin
(M0445) Does this patient have a Pressure Ulcer?
D 0 - No [If No, go to M0468]
DEFINITION: (M0445, M0450, M0460) WOCN Guidance Pressure Ulcer: Any lesion caused by unrelieved pressure resulting in damage of underlying prominences and are staged to classify the degree of tissue damage observed.
tissue. Pressure ulcers are usually located over bony
DEFINITION: (M0450, M0460) WOCN Guidance Pressure Ulcer Stages: Stage 1 through Stage 4 the same as listed in M0450 Non-observable: Wound is unable to be visualized due to an orthopedic device, dressing, etc. A pressure ulcer cannot be accurately staged until the deepest viable tissue layer is visible; this means that wounds covered with eschar and/or slough cannot be staged. and should be documented as non-observable. Indications for predicting pressure ulcer risk? DYes DNo Complete Braden Scale form per organizational guideline (Briggs #3166). (M0450) Current Number of Pressure Ulcers at Each Stage: (Circle one response for each stage.)
Pressure Ulcer Stages
a) Stage 1: Nonblanchable erythema of intact skin; the heralding of skin ulceration. In darker-pigmented skin, warmth, edema, hardness, or discolored skin may be indicators. 0 0
Number of Pressure Ulcers
1 1 2 2 3 3 4 or more 4 or more 4 or more
b) Stage 2: Partial thickness skin loss involving epidermis and/or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. c) Stage 3: Full-thickness skin loss involving damage or necrosis of subcutaneous tissue which may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
0
2
1~
3
l!!ffi]
2
l!!ffi]
3
l!!ffi]
4 or more
d) Stage 4: Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule, etc.) e)
0
1t!l
~
~
~
In addition to the above, is there at least one pressure ulcer that cannot be observed due to the presence of eschar or a non removable dressing, including casts? DO - No D 1 - Yes
© 2007 Briggs Medical Service Company
is the intellectual (800) 247-2343 www.BriggsCorp.com. The Outcome and ASsessment Information Set (OASIS) property of the Center for Health Services and Polley Research, Denver, Colorado. It is used with permission.
Form 3495P-OB
PHYSICAL THERAPY ASSESSMENT
with OASIS ELEMENTS
Page 6 of 16
-,,-_.,
..--../
.-.....-- .
-.--------- .
.I.f,'.
(M0360) Primary Caregiver taking lead responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff):
o
~
o No Problem o Congestion 0 Epistaxis o Loss of smell 0 Sinus prob.
o
o Dysphagia o Lesions
No Problem 0 Hoarseness 0 Sore throat
0 - No one person [If No one person, 1 - Spouse or significant 2 - Daughter or son 3 - Other family member 4 - Friend or neighbor or community 5 - Paid help UK - Unknown Caregiver [If Unknown, (name) other
go to M0390]
o Other
(specify)
•• 0 Other (specify)
d
o o
or church member
o
o
o No
go to M0390]
Problem
Upper / Lower / Partial
0 Masses /Tumors
Primary
--+'.,.......~:.a---'-----'- •..••. :..:.------:A-c
o
Ulcerations
0 Toothache
Phone Number (if different from patient) Relationsh ip/ Health status Other (specify)
---J~~~:....9~.l-L_
---I.61'-~~t-",--'+' _..L!<~L.....:=---
Able to safely care for patient _
(M0370) How Often does the patient receive primary caregiver? o 1 - Several times during day and night ~
assistance
from
the
(M040P) Hearing and Ability to Understand Spoken Language in t's own language (with hearing aids if the patient usually uses them): o observable impairment. Able to hear and understand complex or detailed instructions and extended or abstract conversation. 1 - With minimal difficulty, able to hear and understand most multistep instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice. moderate difficulty hearing and understanding simple, one-step instructions and brief conversation; needs frequent prompting or assistance.
o
o
o o o
3 4 5 6
-
Several times during day Once daily Three or more times per week One to two times per week Less often than weekly
o
o 2 - Has o 3o 4-
UK - Unknown
(M0380) Type of Primary Caregiver Assistance: (Mark all that apply.) - 1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding) ~ 2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, (.telephone, shopping, finances) ~3 - Environmental support (housing, home maintenance) 'qO 4 - Psychosocial support (socialization, companionship, recreation) i;zl 5 - Advocates or facilitates patient's participation in appropriate medical care o 6 - Financial agent, power of attorney, or conservator of finance
Has severe difficulty hearing and understanding simple greetings and short comments. Requires multiple repetitions, restatements, demonstrations, additional time. Unable to hear and understand familiar words expressions consistently, ill patient nonresponsive. or common
o No o HOH: R / L o Vertigo o Other (specify)
Problem 0 Hearing aid: R / L L _
o Deaf: R / L o Tinnitus: R /
o
7 - Health care agent, conservator attorney - Unknown
of person, or medical power of
o UK
,) Vision with corrective
lenses if the patient usually wears them: in most situations; can see med(M0410) Speech and Oral (Verbal) Expression own language): and easily in all situations of Language
- Normal vision: sees adequately ication labels, newsprint.
•
(in patient's
k",,_1 -. PartialiY!mpaired:
cannot see medication labels or ne';spriri't,but, can see obstacles in path, and the surrounding layout; can count ,fingers at arm's length. ~--.~~ them ill patient nonr~ponsive. ~ Problem - --. --.-~
Of) - Expresses complex ideas, feelings, and needs clearly, completely,
with no observable impairment.
'0 2 - Severely impaired: cannot locate objects without hearing or touching
o 1 - Minimal
o2
o No o Glasses 0 Contacts: o Other (specify)
R/ L
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).
0 Glaucoma
_
- 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. - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener. Speech limited to single words or short phrases. - Unable to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible). - Patient nonresponsive or unable to speak.
o3 o4 o5
Form 3495P·08
© 2007 Briggs Medical Service Company
is the intellectual
(SOO) 247·2343 www.BriggsCorp.com. The Outcome and ASsessmentlnformalion Set (OASIS) properly of the Center for Health Services and Policy Research, Denver, Colorado. It is used with permission.
PHYSICAL THERAPY ASSESSMENT
with OASIS ELEMENTS
Page 4 of 16
~.
---------
.'----".
-0------,-
.~
Patient Name
10
PATIENT HISTORY
#================_
f
o
o
a. b.
(M0175) From which of the following Inpatient Facilities was the ient discharged during the past 14 days? (Mark all that apply.) 1 - Hospital •
. 2 - Rshabiutafion facility
3 - Skilled nursing facility 4 - Other nursing home 5 - Other (specify) - Patient was not discharged [If NA, go to M0200] In~'ltient
day
(M0210) List the patient's Medical Diagnosis and ICD-9-CM codes at the level of highest specificity for those conditions requiring changed medical or treatment regimen (no surgical, E-codes, or V-codes): Changed Medical Regimen Diagnosis ICD-9-CM a. ( ( ( ( •
e__ e __ e __
)
) ) )
_ from an inpatient facility
b. c. d.
o NA
(~)80)
J __ /_Y._/_1o.!1::h.
month year
Dischar~
Date (most recent); 0 UK - Unknown
(M0190) List each Inpatient Diagnosis and ICD-9-CM code at the level of highest specificity for only those conditions treated during an inpatient stay within the last 14 days (no surgical, E-codes, or V-codes): Inpatient Facility Diagnosis ( ( ICD-9-CM
e__ e__ ) )
(M0200) Medical or Treatment Regimen Change Within Past 14 Days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days? 0 - No [If No, go to M0220] 01 - Yes
o
(M0220) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.) o 1 - Urinary incontinence o 2 - Indwelling/suprapubic catheter o 3 - Intractable pain o 4 - Impaired decision-making o 5 - Disruptive or socially inappropriate behavior o 6 - Memory loss to the extent that supervision required o 7 - None of the above o NA - No inpatient facility discharge and no change in medical or treatment regimen in past 14 days o UK - Unknown
(M0230/M0240/M0246) Diagnoses, Severity Index, and Payment Diagnoses: List each diagnosis for which the patient is receiving home care (Column 1) and enter its ICD-9-CM code at the level of highest specificity (no surgical/procedure codes) (Column 2). Rate each condition (Column 2) using the severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.) V codes (for M0230 or M0240) or E codes (for M0240 only) may be used. ICD-9-CM sequencing requirements must be followed if multiple coding is indicated for any diagnoses. If a V code is reported in place of a case mix diagnosis, then optional item M0246 Payment Diagnoses (Columns 3 and 4) may be completed. A case mix diagnosis is a diagnosis that determines the Medicare PPS case mix group. Code each row as follows: Column 1: Enter the description of the diagnosis. Column 2: Enter the ICD-9-CM code for the diagnosis described in Column 1; Rate the severity of the condition listed in Column 1 using the following scale: o - Asymptomatic, no treatment needed at this time 1 - Symptoms well controlled with current therapy 2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring 3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring 4 - Symptoms poorly controlled, history of re-hospitalizations Column 3: (OPTIONAL) If a V code reported in any row in Column 2 is reported in place of a case mix diagnosis, list the appropriate case mix diagnosis (the description and the ICD-9-CM code) in the same row in Column 3. Otherwise, leave Column 3 blank in that row. Column 4: (OPTIONAL) If a V code in Column 2 is reported in place of a case mix diagnosis that requires multiple diagnosis codes under ICD-9-CM coding guidelines, enter the diagnosis descriptions and the ICD-9-CM codes in the same row in Columns 3 and 4. For example, if the case mix diagnosis is a manifestation code, record the diagnosis description and ICD-9-CM code for the underlying condition in Column 3 of that row and the diagnosis description and ICD-9-CM code for the manifestation in Column 4 of that row. Otherwise, leave Column 4 blank in that row. (M0230) Primary Column Diagnosis 1 & (M0240) Other Diagnoses Column 2 ICO-9-CM and severity rating for each condition. Description (M0230) Primary a. Diagnosis Jlocator m~ a. ICD-9-CM Column
'''~h 3
IICD-9-CM
I] f"ir.i.fu
---
••. "t£l...•• .l :.111[' C
-----
_
.. _--
-
-_
..
_-_
..
_--_
...
_-
Complete only if a V code in Column 2 is reported in place of a case mix diagnosis. Description
Column 4 Complete only if the V code in Column 2 is reported in place of a case mix diagnosis that is a multiple coding situation (e.g., a manifestation code) Description IICD-9-CM
~l[V1Cb~
Date
f
I
cdl#5k
/ OlE
i[6caforf13~
(------) 00 01 02
I Severity Rating N codes are allowed) Cpo e .1/:
1
N or E codes NOT allowed)
a. (
e
N or E codes NOT allowed)
a. (
e
03
04
)
)
(M0240) Other Diagnoses b. Date
C.
N or E codes are allowed)
b.
(____ e __ )
Nor E codes NOT allowed)
b.
( C.
e
N or E codes NOT allowed)
b. ( c.
e
I I / I I
I I_/_-
OlE
c.
DO
01
02
03
e __
04
)
)
)
(____
Date
OlE
d. OlE e.
00
01
02
03
e __
04
)
( d. ( e. ( f.
e
) d.
(
e
)
d.
Date e. Date f. Date
Form 3495P-08
(____
00
01
02
03
e __
04
)
e
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)
(____
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f.
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(____
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00
01
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(-
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)
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}
© 2007 Briggs Medical Service Company
is the intellectual
(800) 247-2343 www.BriggsCorp.com. The Outcome and ASsessment Information Set (OASIS) property of the Center for Health Services and POlicy Research, Denver, Colorado. It is used with permission.
Page 2 of 16
PHYSICAL THERAPY ASSESSMENT
with OASIS ELEMENTS