HTML Preview Home Health Care Plan page number 1.
Department of Health and Human Services Form Approved
Centers for Medicare & Medicaid Services
OMB No. 0938-0357
HOME HEALTH CERTIFICATION AND PLAN OF CARE
1. Patient's HI Claim No. 2. Start Of Care Date 3. Certification Period
6. Patient's Name and Address 7. Provider's Name, Address and Telephone Number
4. Medical Record No. 5. Provider No.
From: To:
10. Medications:
11. ICD-9-CM
12. ICD-9-CM
Date
Date
13. ICD-9-CM Date
8. Date of Birth
9. Sex
Principal Diagnosis
Other Pertinent Diagnoses
Surgical Procedure
14. DME and Supplies 15. Safety Measures:
17. Allergies:
16. Nutritional Req.
F
M
Dose/Frequency/Route (N)ew (C)hanged
18.A. Functional Limitations
18.B. Activities Permitted
1
Amputation
5
Paralysis
9
Legally Blind
1
Complete Bedrest
6
Partial Weight Bearing
A
Wheelchair
2
Bowel/Bladder (Incontinence)
6
Endurance
A
Dyspnea With
Minimal Exertion
2
Bedrest BRP
7
Independent At Home
B
Walker
3
Contracture
7
Ambulation
B
Other (Specify)
3
Up As Tolerated
8
Crutches
C
No Restrictions
4
Hearing
8
Speech
4
Transfer Bed/Chair
9
Cane
D
Other (Specify)
5
Exercises Prescribed
19. Mental Status:
1
Oriented
3
Forgetful
5
Disoriented
7
Agitated
2
Comatose
4
Depressed
6
Lethargic
8
Other
20. Prognosis:
1 Poor 2
Guarded
3 Fair
4 Good 5 Excellent
21. Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)
22. Goals/Rehabilitation Potential/Discharge Plans
24.
26.
23. 25.
27. 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.
I certify/recertify that this patient is confined to his/her home and needs
intermittent skilled nursing care, physical therapy and/or speech therapy or
continues to need occupational therapy. The patient is under my care, and I have
authorized the services on this plan of care and will periodically review the plan.
Physician's Name and Address
Nurse's Signature and Date of Verbal SOC Where Applicable: Date HHA Received Signed POT
Attending Physician's Signature and Date Signed
Form CMS-485 (C-3) (02-94) (Formerly HCFA-485) (Print Aligned)