POCPRO

ICD10 Input

SOC RECERT ROC

Header

OASIS DATE:

HOME HEALTH:

NURSE NAME:

Patient Info

Priority Code:

Contact / Phone:

Needs Interpreter

Language:

Sensory Status:

Mental Health: Mental Health Disability Psychosocial

Physical Functional Cognition

Psychosocial Status:

Patient Stated Goal(s):

Fall Risk:

Vitals

BP: Temp: Pulse: Resp:

Weight (lbs): Height (in):

Pain

Patient has no pain

Pain Sites:

Pain Level:

Pain Relief:

Pain Relief (text):

Edema:

Crackles/Pulse:

Medications

Blood Thinner(s):

Injection(s):

Other Psych Meds:

Services

SN: WEEKS:

PT REF

OT REF

MSW REF

ST REF

CHHA: REF

Items

M Codes

M1100:

M1400:

M1610:

Hospital Risks

History of falls -Action: Home safety evaluation; ongoing fall risk assessment; Risk based fall prevention program; Patient/PCG education{PT8}{OT8}

Unintentional weight loss -Action: Nutritional screening and assessment.

Multiple Hospitalizations -Action: Front-loading visits, Close care-coordination with MD/Hospital, Medication management and education, Assess patient's knowledge, ability, resources, adherence, Patient/PCG education.

Multiple ER Visits -Action: Front-loading visits, Close care-coordination with MD/Hospital, Medication management and education, Assess patient's knowledge, ability, resources, adherence, Patient/PCG education.

Decline in mental, emotional, or behavior status -Action: Psychosocial screening; Patient/PCG education.

Reported/observed history of difficulty complying with any medical instructions in the past 3 months -Action: Pt/PCG education, medication reconciliation every SN visits.

Currently taking 5 or more medications -Action: Teach actions and side effects; teach disease process and s/s of exacerbations of chronic illness; assess pt's ability, knowledge, resource, adhere.

Currently reports exhaustion -Action: Educate patient/pcg on management of activity intolerance and energy conservation/relaxation techniques.

Other risk(s) not listed{HOSP_NINE}

Emergency Preparedness

*** Obtained the patient emergency contact number(s) for the medical record.

*** Discussed the HHA plans for supporting their patients during a natural or man-made disaster.

*** Discussed patient specific emergency planning options.

*** Discussed the development of the patient individualized emergency preparedness plan of care, including self-care readiness and the procedure to follow up with the HHA in the event services are interrupted.

*** State and local emergency preparedness officials notified about the possible need for evacuation.

*** List of recommended items to have prepared/ready and available in the event of an emergency.

*** Educational materials provided to suggest/assist with emergency management/decision making priorities.

*** List of local and state approved evacuation routes and community shelters relevant to the patient specific geographic location.

*** Written materials to restate/reinforce the emergency preparedness procedures given to the {REP}.

Blood Sugar

Controlled with Diet

Insulin(s):

Check:

Level:

Range:

DM Inj by: Patient Caregiver SN Family

Sleep / Rest

Adequate Inadequate

Wound

WOUND:

CARE:

Ulcer

ULCER:

CARE:

IV

INFUSE:

FLUSH:

Ostomies

Other

BT (Bowel Training):

SSTG: Active