Form Cms-485 Home Health Certification And Plan Of Care

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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
4. Medical Record No.
5. Provider No.
6. Patient's Name and Address
7. Provider's Name, Address and Telephone Number
8. Date of Birth
9. Sex
10 .Medications: Dose/Frequency/Route (N)ew (C)hanged
11. ICD-9-CM
Principal Diagnosis
Date
12. ICD-9-CM - Surgical Procedures - Date
13. ICD-9-CM - Other Diagnoses - Date
15. Safety Measures
14. DME and Supplies
16. Nutritional Req.
17. Allergies:
18.B. Activities Permitted
18.A. Functional Limitations
1
Complete Bed Rest
6
Partial Weight Bearing A
Wheelchair
1
Amputation
5
Paralysis
8
Speech
2
Bedrest BRP
7
Independent At Home
B
Walker
2
Bowel/Bladder
6
Endurance 9
Legally Blind
(Incontinence)
3
Up as Tolerated
8
Crutches
C
No Restrictions
3
Contracture
7
Ambulation A
Dyspnea
4
Transfer Bed-Chair
9
Cane
D
Other (Specify)
w/minimal
exertion
5
Exercises Prescribed
Other (Specify)
4
Hearing
B
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
23. Nurse's Signature and Date of Verbal SOC Where Applicable:
25. Date HHA Received Signed POT
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485ID: 2948

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