Department of Health and Human Services Health Care Financing Administration                                                                                                                                   Form Approved OHB No. 0938-0357
Home Health Certification and Plan of Care
1. Patient's HI Claim No.
23423-1		 2. Start of Care Date
04/02/2004		 3. Certification Period
From:   04/02/2004 To:  06/01/2004		 4. Medical Record No.
23423-1		 5. Provider Number
234567
6. Patient's Name and Address
Patient , Sample
124 Main Street
Houston, TX 77009
(555) 123 - 7777		 7. Provider's Name, Address and Telephone Number
Hester QA
1759 South
Houston, TX 77054
(713) 555-1212
8. Date of Birth:02/02/1938 9. Sex checked M checked F
11. ICD-9-CM
250·		 Principal Diagnosis
DIABETES MELLITUS (O)		 Date
02/02/2004
12. ICD-9-CM
N/A 		Surgical Procedure
N/A 		Date
N/A
13. ICD-9-CM
781·8
413·1 		Other Pertinent Diagnosis
NEUROLOGICAL NEGLECT SYND (E)
PRINZMETAL ANGINA ( ) 		Date
03/03/2004
10. Medications: Dose/Freq./Route (N)ew (C)hanged
Monopril 10mg 1qd PO (N)
ASA 325mg QD PO (N)
Clelbrex 1 q6h prn Pain PO (n)
14. DME and Supplies
Bedside Commode;Tub/Shower Bench ;Ace Wrap ;Chux/Underpads
;Exam Gloves ;Kerlix Rolls ;Sterile Gloves 		15. Safety measures
O2 Precautions ;Keep Side Rails Up;Keep Pathway Clear;Safety in ADL's
16. Nutritional Requirements
1800 cal ada

17. Allergies
NKA (Food/ Drug/ Latex);  
18.A. Functional Limitations
1. checked Amputation 6. checked Endurance
2. checked Bowel/Bladder Incontinence 7. checked Ambulation
3. checked Contracture 8. checked Speech
4. checked Hearing 9. checked Legally Blind
5. checked Paralysis
A. checked Dyspnea
B. checkedOther (Specify):
18.B. Activities Permitted
1. checkedComplete Bedrest 6. checkedPart Wt Bearing
2. checked Bedrest BRP 7. checked Ind at home
3. checkedUp as Tolerated 8. checked Crutches
4. checked Transfer Bed/Chair 9.checkedCane
5. checked Exercise Prescribed
A. checked Wheelchair B. checked Walker
C. checked No Restrictions D. Other: (specify)
19. Mental Status 1. checkedOriented 3. checkedForgetful 5. checked Disoriented 7. checkedAgitated
2. checkedComatose 4. checkedDepressed 6. checked Lethargic 8. checkedOther
20. Prognosis checked1. Poor     checked2. Guarded     checked3. Fair     checked4. Good     checked5. Excellent    
21. Orders for Discipline and Treatments (Specify Amount/ Frequency/ Duration)
SN Frequency: 1w9
PT Frequency: eval
 HHA Frequency: 2w9
22. Goals/ Rehabiliation Potential/ Discharge Plans
The Pt/Cg will verbalize of disease process.
The Pt/Cg will verbalize understanding of medications.
The patients hygiene needs will be met with the assistance of a home health aide.
The patients mobility will be enhanced.
 The patients upper extremity mobility will be enhanced to facilitate independence.
Pt/Cg will have access to community resources to facilitate recovery.
23. Nurse Signature and Date of Verbal SOC Where Applicable


 25. Date HHA Received Signed POT
24. Physician's Name and Address
Dr. Paul Smith MD
3333 West Main Houston TX 77030
(713) 555-3333           UPIN 42423 		26. 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 continue 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.
27. Attending Physician's Signature and Date Signed 28. Anyone who misrepresents, falsifies, or conseals essential information required for payment of Federal funds may be subject to fine, imprisonment, or cival penalty un applicable Federal laws.
Form HCFA-485 (U4) (2-94)                                                                  Page 1 of 2
Department of Health and Human Services Health Care Financing Administration                                                                                                                                   Form Approved OHB No. 0938-0357
Addendum to Plan of Care
1. Patient's HI Claim No.
23423-1		 2. Start of Care Date
04/02/2004		 3. Certification Period
From:   04/02/2004 To:  06/01/2004		 4. Medical Record Number
23423-1		 5. Provider Number
234567
6. Patient's Name
Patient , Sample
 7. Provider's Name
Hester QA
13. Other Pertinent Diagnosis

V16·6
FAMILY HISTORY OF LEUKEMIA ( )
9. Signature of Physician


 10. Date
11. Optional Name/ Signature of Nurse/ Therapist


 12. Date
Form HCFA-487 (C4) (4-87)                                                                 Page 2 of 2