Physician Progress Note For Face To Face Encounter And Certification Of Eligibility For Home Health Services Form - Grey Page 2
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2Patient Name: _____________________________________________________________ Date of F2F Encounter: ____________________________
Plan:
This patient requires skilled nursing to:
Teach the patient/caregiver to: __________________________________________________
________________________________________________________________________________
q Administer the following:
q IV
q IM
q SQ medication(s) that the patient/
caregiver cannot safely administer: ___________________________________________
_____________________________________________________________________________
q Provide skilled assessment and teaching of oral medications because:
q Regimen is highly complex
q Patient is confused
q Patient has new medications ordered
q Patient is experiencing side effects
q Non-adherence to medication regimen is suspected
q other (explain): ____________________________________________________________
______________________________________________________________________________
q Administer infusion therapy that the patient/caregiver cannot safely administer
q Perform skilled:
q Wound Care
q Catheter Care
q Ostomy Care that the
patient/caregiver cannot administer or there is no caregiver
available to render the care.
q Instruct on Disease Management: _____________________________________________
q Assess and provide instruction on pain management
q Other: _______________________________________________________________________
This patient requires:
q To assess and provide instruction on improving functional mobility at home
q Physical Therapy
q To assess and provide gait training, strengthening, and/or balance exercises to
restore the patient’s ability to ambulate or transfer safely
q Occupational Therapy
q To teach patient and caregivers on non-pharmacologic pain reduction
q Speech Language Pathology
techniques and strategies
q To increase strength and endurance and restore range of motion post-surgery
Surgical procedure: __________________________________________________________
q To evaluate the need for assistive/adaptive devices or environmental
modifications needed to address functional deficits and improve safety in
performing ADLs
q To provide and instruct on home exercise program
q To assess and provide instruction on managing dysphagia safely
q To assess and provide instruction on managing aphasia and other
language disorders
q Other (describe): _____________________________________________________________
_____________________________________________________________________________
This patient requires:
Describe why the patient needs these additional services: ________________________
q MSW
________________________________________________________________________________
q HHA
Signature of Physician, Podiatrist, Nurse Practitioner, or Physician Assistant Completing the Encounter Documentation:
________________________________________________________________________________________________________________________________
(Include Hand Written Date)
After signing this form, please place a copy in the patient’s medical
record and fax a copy to Advocate at Home at 630.368.5930.
Page 2/2
12/15 MC 2656
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