DOH-4359 (2010)
PHYSICIAN’S ORDER FOR PERSONAL CARE/CONSUMER DIRECTED PERSONAL ASSISTANCE SERVICES
COMPLETE ALL ITEMS
INCOMPLETE FORMS WILL BE RETURNED TO THE PHYSICIAN
1. Patient Identifying Information
(Use Additional Paper If Necessary)
PATIENT NAME
CIN
DATE OF BIRTH
SEX
ADDRESS: APT/STREET
CITY
STATE
ZIP CODE
IF CURRENTLY HOSPITALIZED: Name of Hospital
ANTICIPATED DATE OF DISCHARGE
TELEPHONE NO.
MEDICARE NO.
:
DATE OF ADMISSION
(
)
TO ABOVE ADDRESS?
YES
NO
IF NO EXPLAIN:
2. General Information
PHYSICIAN NAME
LICENSE #
TELEPHONE NO.
(
)
ADDRESS: STREET
CITY
STATE
ZIP CODE
If the examination was conducted by a Physician’s Assistant, Specialist’s Assistant, or Nurse Practitioner, Identify:
Name
Profession:
License #
PLACE OF EXAMINATION:
DATE OF EXAMINATION:
3. Medical Findings
NOTE: Indicate N/A if an item does not apply to this patient or Unk if the requested information is unknown to the physician signing this form.
Height:
Weight:
For the condition(s) requiring personal care:
Primary Diagnosis
ICD-9-CM Code
Secondary Diagnosis
ICD-9-CM Code
Describe the patient’s current medical/physical condition
Is the patient’s condition stable?
Yes
No
Is the patient appropriate for Hospice care?
Yes
No
Describe the current treatment plan and therapeutic goals including the prognosis for recovery:
Describe any prohibited activities or functional limitations:
Is the patient self-directing?
Yes
No
Is the patient able to summon help by any means?
Yes
No
If no, explain
Is the patient able to ambulate independently?
Yes
No
With devices?
Yes
No
Other Assistance?
Yes
No
Describe:
Is the patient continent of bowel?
Yes
No of bladder?
Yes
No
Catheter/Colostomy Needs:
List all current medications (prescription and OTC) and note dosage and frequency and any special instructions (attach additional sheet if necessary):
Can the patient self-administer medications:
Yes
No
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