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    Home Health Certification and Plan of Care

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    lokohugpo
    This document is a home health certification and plan of care for patient Alfredo Delgado. It summarizes his medical history including diagnoses of hypertensive heart disease, congestive heart failure, uncontrolled type 2 diabetes, and obesity. It outlines his medication regimen and orders for skilled nursing including daily monitoring of vital signs and blood pressure/glucose for 14 days to assess for complications. The goals are to ensure medication compliance and stabilization of his cardiovascular and pulmonary conditions and demonstrate competence in his medical regimen. The attending physician certifies that Mr. Delgado is homebound and requires intermittent skilled nursing services.

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    Home Health Certification and Plan of Care

    Uploaded by

    lokohugpo
    103 views2 pages
    This document is a home health certification and plan of care for patient Alfredo Delgado. It summarizes his medical history including diagnoses of hypertensive heart disease, congestive heart failure, uncontrolled type 2 diabetes, and obesity. It outlines his medication regimen and orders for skilled nursing including daily monitoring of vital signs and blood pressure/glucose for 14 days to assess for complications. The goals are to ensure medication compliance and stabilization of his cardiovascular and pulmonary conditions and demonstrate competence in his medical regimen. The attending physician certifies that Mr. Delgado is homebound and requires intermittent skilled nursing services.

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    Alfredo

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    This document is a home health certification and plan of care for patient Alfredo Delgado. It summarizes his medical history including diagnoses of hypertensive heart disease, congestive heart failure, uncontrolled type 2 diabetes, and obesity. It outlines his medication regimen and orders for skilled nursing including daily monitoring of vital signs and blood pressure/glucose for 14 days to assess for complications. The goals are to ensure medication compliance and stabilization of his cardiovascular and pulmonary conditions and demonstrate competence in his medical regimen. The attending physician certifies that Mr. Delgado is homebound and requires intermittent skilled nursing services.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC or read online from Scribd
    Download as doc
    103 views2 pages

    Home Health Certification and Plan of Care

    Uploaded by

    lokohugpo
    This document is a home health certification and plan of care for patient Alfredo Delgado. It summarizes his medical history including diagnoses of hypertensive heart disease, congestive heart failure, uncontrolled type 2 diabetes, and obesity. It outlines his medication regimen and orders for skilled nursing including daily monitoring of vital signs and blood pressure/glucose for 14 days to assess for complications. The goals are to ensure medication compliance and stabilization of his cardiovascular and pulmonary conditions and demonstrate competence in his medical regimen. The attending physician certifies that Mr. Delgado is homebound and requires intermittent skilled nursing services.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC or read online from Scribd
    Download as doc
    of 2

    Department of Health and Human Services Form Approved

    Centers fro Medicare and Medicaid Services OMB No. 0938-0357


    HOME HEALTH CERTIFICATION AND PLAN OF CARE
    1. Patient's HI 2. Start Of 3. Certification Period 4. Medical Record 5. Provider No.
    Claim No. Care Date From: 2/6/2009 To: 4/6/2009 No. N/A
    N/A 2/6/2009
    6. Patient's Name and Address: 00015
    7. Provider's Name, Address and Telephone Number:
    ALFREDO DELGADO NEW LIFE HOME HEALTH AGENCY, INC.
    10251 NW 80 COURT APTO # 413 6501 NW 36 STREET, SUITE 455
    HIALEAH, FLORIDA 33016 VIRGINIA GARDENS, FLORIDA. 33166
    ( 786) 308 7297 PHONE # 305 -817-0884 FAX # 305-871-4818
    8. Date of Birth 07/08/1939 9. Sex M
    ✘ 10. Medications: Dose/Frequency/Route (N)ew
    11. ICD-9- Principal DiagnosisF Date (C)hanged:
    OXYGEN 2 L/MIN VIA N/C INTERMITTENTLY AS NEEDED
    CM HYPERTENSIVE HEART DIS. 1/27/09 FOR SHORTNESS OF BREATH
    402.11
    12. ICD-9- Surgical Procedure Date PLAVIX 75 MG ONE TABLET ONCE A DAY ORALLY
    CM TRICOR 145 MG ONE TABLET ONCE A DAY ORALLY
    NAMENDA 10 MG ONE TABLET ONCE A DAY ORALLY
    13. ICD-9- Other Pertinent Date METOLAZONE 5 MG ONE TABLET ONCE A DAY ORALLY
    CM Diagnoses 1/27/09 SYNTHROID 75 MCG ONE TABLET ONCE A DAY ORALLY
    428.0 CONGESTIVE HEART FAILURE 1/27/09 AVALIDE 300 MG ONE TABLET ONCE A DAY ORALLY
    250.02 DM UNCONTROLLED TYPE 2 1/1/08
    OBESITY NOS ASPIRIN 81 MG ONE TABLET ONCE A DAY ORALLY
    278.00

    14. DME and Supplies: GLOVES, THERMOMETER, B/P 15. Safety Measures: PATIENT CORRECT
    CUFF, GLUCOMETER. LANCETS, CHEMSTRIPS, IDENTIFICATION, MEDICATION RECONCILIATION, FALL
    ALCOHOL PADSReq. NO CONCENTRATED SWEETS
    16. Nutritional PRECAUTIONS
    17. Allergies: NONE KNOWN ALLERGIES
    18.A. Functional Limitations 18.B. Activities Permitted
    1 Amputation 5 Paralysis 9 Legally 1 Complete 6 Partial Weight A Wheelchair
    Blind Bedrest Bearing
    2 Bowel/Bladder 6 ✘ A ✘ Dyspnea 2 Bedrest BRP 7 Independent at B Walker
    (incontinence) Endurance With Home
    3 Contracture 7 Minimal 3 ✘ Up As 8 Crutches C No
    Ambulation Exertion Tolerated Restrictions
    4 Hearing 8 Speech B ✘ Other 4 Transfer 9 ✘ Cane D Other
    (Specify Bed/Chair (Specify)
    5 Exercises
    19. Mental Status: 1 ✘ Oriented 3 ✘ Forgetful 5 Disoriented 7 Agitated

    2 4 6 Lethargic 8 Other
    20. Prognosis: Comatose
    1 Poor Depressed
    2 Guarded 3 ✘ Fair 4 Good 5 Excellent
    21. Orders for Discipline and Treatments (Specify Amount/Frequency/Duration):
    SN FREQUENCY: 1/DAY FOR 14 DAYS
    SKILLED OBSERVATION/ASSESSMENT, ASSESS VITAL SIGNS AND SIGN/SYMPTOMS OF COMPLICATIONS:
    CARDIOVASCULAR/RESPIRATORY SYSTEM. ASSESS PATIENT’S RESPONSE TO AND COMPLIANCE WITH PLAN OF
    CARE ON EVERY VISIT. INSTRUCT /EVALUATE UNDERSTANDING OF : DISEASE PROCESS, MEDICATION REGIMEN,
    ( ACTION/SIDE EFFECTS), DETECTING COMPLICATIONS, DIET/NUTRITIONAL STATUS, SAFETY PRECAUTIONS AND
    EMERGENCY MEASURES. SN TO MONITOR BLOOD PRESSURE LEVELS DAILY FOR 14 DAYS, MAINTAIN A LOG AT
    HOME TO REPORT TO PHYSICIAN UPON REQUEST, AND NOTIFY PHYSICIAN IF BLOOD PRESSURE LESS THAN 90/60
    MMHG OR GREATER THAN 160/90 MMHG, SN TO ASSESS FOR SIGNS/SYMPTOMS OF UNCONTROLLED
    HYPERTENSION: TINNITUS, DIZZINESS, OR NASAL BLEEDING. SN TO ASSESS FOR IRREGULAR HR, PALPITATIONS,
    TACHYCARDIA OR BRADYCARDIA, FLUID RETENTION OR EDEMA. SN TO MONITOR BLOOD GLUCOSE VIA
    GLUCOMETER DAILY FOR 14 DAYS, MAINTAIN A LOG AT HOME, REPORT TO PHYSICIAN UPON REQUEST. INSTRUCT
    PATIENT ON DISEASE PROCESS & COMMON COMPLICATIONS, PRESCRIBED DIET & SHOPPING ADVICE ,
    INSTRUCT S/S HYPO/HYPERGLYCEMIA AND EMERGENCY PROCEDURES. INSTRUCT GOOD SKIN CARE AND FOOT
    CARE, DAILY CARE OF TEETH.
    22. Goals/Rehabilitation Potential/Discharge Plans:
    SN GOALS
    PATIENT DEMONSTRATES COMPLIANCE WITH MEDICATION
    STABILIZATION OF CARDIOVASCULAR PULMONARY CONDITION
    PATIENT DEMONSTRATES COMPETENCE IN FOLLOWING MEDICAL REGIME
    23. Nurse's Signature and Date of Verbal SOC Where Applicable: 25. Date HHA Received Signed POT
    24. Physician's Name and Address: 26. I certify/recertify that this patient is confined to his/her
    CARMEN ORTIZ BUTCHER, MD UPIN # D82654 home and needs
    11760 BIRD ROAD SW 40 STREET, SUITE 403 Intermittent skilled nursing care, physical therapy and/or
    MIAMI, FL 33175 speech therapy or
    continues to need occupational therapy. The patient is
    305- 226-7760 FAX # 305-226- 7798
    under my care, and I have authorized the services on this
    27. Attending Physician's Signature and Date Signed 28. Anyone who misrepresents, falsifies, or conceals essential
    information required for payment of Federal funds may be
    subject to fine, imprisonment, or civil penalty under
    applicable Federal laws.

    Form CMS-485 (C-4) (02-94) ✘ Provider Intermediary Provider


    Physician

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