Scribd
Upload
22 views1 page

Doh 3726

The document is a Home Health Certification and Plan of Treatment form used for patient identification and care management. It includes sections for patient and provider information, medical diagnoses, treatment orders, and prognosis. The form requires signatures from the attending physician to certify the need for home health services.

Uploaded by

alfie.previti
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
22 views1 page

Doh 3726

The document is a Home Health Certification and Plan of Treatment form used for patient identification and care management. It includes sections for patient and provider information, medical diagnoses, treatment orders, and prognosis. The form requires signatures from the attending physician to certify the need for home health services.

Uploaded by

alfie.previti
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

HOME CARE AI485

H O M E H E A LTH C E R TIFIC A TIO N A N D P LA N O F TR E A TM E N T


1. Patient's Identification Num ber 2. SO C Date 3. Certification Period 4. Medical Record 5. Provider No.
From : To:

6. Patient's Nam e and Address 7. Provider's Nam e and Address

8. Date of Birth 10. Medications: Dose/Frequency/Route (N)ew (C)hanged


9. Sex
” M” F
11. ICD-9-CM Principal Diagnosis Date

12. ICD-9-CM Surgical Procedure Date

13. ICD-9-CM Other Pertinent Diagnoses Date

14. DME and Supplies/Nutritional Assessment & Counseling/Lab Test 15. Safety Measures

16. Nutritional Reg. 17. Allergies:

18.B Activities Perm itted


18.A Functional Lim itations
1 ” Com plete Bedrest 6 ” Partial W eight Bearing A ” W heelchair
1 ” Am putation 5 ” Paralysis 9 ” Legally Blind
2 ” Bedrest BR P 7 ” Independent at H om e B ” W alker
2 ” Bow el/Bladder 6 ” Endurance A ” Dyspnea W ith
3 ” Up as Tolerated 8 ” C rutches C ” No Restrictions
(incontinence) 7 ” Am bulation M inim al Exertion
4 ” Transfer Bed/Chair 9 ” C ane D ” Other (Specify)
3 ” Contracture 8 ” Speech B ” O ther (Specify)
5 ” Exercise Prescribed
4 ” Hearing

19. Mental Status


1 ” Oriented 2 ” Com atose 3 ” Forgetful 4 ” Depressed 5 ” Disoriented 6 ” Lethargic 7 ” Agitated 8 ” O ther

20. Prognosis
1 ” Poor 2 ” G uarded 3 ” Fair 4 ” Good 5 ” Excellent

21. Orders for Discipline and Treatm ents (Specify Am ount/Frequency/Duration)

22. Goals/Rehabilitation Potential/Discharge Plans

23. Verbal Start of Care and Nurse's Signature and Date W here Applicable:

24. Physician's Nam e and Address 25. Date HHA 26 . I ” certify ” recertify that the above hom e health services are
Received Signed PO T required and are authorized by m e with a written plan for treatm ent which
will be periodically reviewed by me. This patient is under my care, is
confined to his/her home, and is in need of interm ittent skilled nursing
care and/or physical or speech therapy or has been furnished hom e
health services based on such a need, no longer has a need for such
care or therapy, continues to need occupational therapy.

27. Attending Physician's Signature (Required on 485 Kept on File in Medical Records of HHA) Date Signed

DOH-3726 (Rev 12/05)

You might also like