Traditional CMS-485 |
Revised CMS-485 |
Demographics/Patient Information |
- Name
- Address
- Date of birth
- Sex
- Start of care date
- Certification period
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SAME |
Provider Information |
- HHA name
- HHA address
- HHA telephone number
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SAME |
Diagnoses and Goals |
Diagnoses
- Principal diagnosis, ICD-9-CM code, and date of onset/exacerbation
- Surgical procedure, ICD-9-CM code, and date
- Other pertinent diagnoses, ICD-9-CM codes, and dates of onset/exacerbation
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Diagnosis
SAME |
Allergies-medication and other
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Allergies-medications and other
- Option to communicate specific drug allergies:
- Penicillin
- Sulfa
- Aspirin
- Codeine
- Other (specify)
- No known allergies
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Functional Limitations
- Amputation
- Bowel/bladder
- Contracture
- Hearing
- Paralysis
- Endurance
- Ambulation
- Speech
- Legally blind
- Dyspnea with minimal exertion
- Other
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Functional Limitations
SAME, with the addition of:
- Dysphagia
- Option to instruct the home care nurse to:
- Assess the functional limitations indicated
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Mental Status
- Oriented
- Comatose
- Forgetful
- Depressed
- Disoriented
- Lethargic
- Agitated
- Other
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Mental Status
SAME |
Prognosis
- Poor
- Guarded
- Fair
- Good
- Excellent
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Prognosis
SAME |
Goals
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Goals
- Option to communicate specific goals to home care nurse:
- Patient/caregiver will be knowledgeable about disease; behaviors needed to manage condition; signs and symptoms of complications; prescribed diet; signs and symptoms of an emergency and know appropriate actions.
- Patient/caregiver will demonstrate proper administration of medication.
- Patient/caregiver will identify purpose, dose, schedule, adverse effects, and contraindications of prescribed medication.
- Patient/caregiver will demonstrate treatment as prescribed.
- Wound will show signs of healing.
- Patient will report a decrease in pain.
- Patient will increase participation in ADLs
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Orders (Heart Failure Specific on Revised Form) |
Discharge Medications
- Dose
- Frequency
- Route
- Indication of "new" and "change" orders as needed
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Discharge Medications
SAME, with the addition of
- Option to instruct the home care nurse to:
- Assess heart failure medications.
- Teach/reinforce roles, side-effects, and dosages of medications.
- Check for medication adherence.
Medication Adjustment
- Option to instruct the home care nurse to:
- Increase _______ by ______ mg each week until blood pressure is ____/____
- Increase _______ by ______ mg each week until pulse is ________
- Notify physician each week with report of vital signs, physical findings, and current medication doses when adjusting medications.
Physician Notification
- Option to instruct the home care nurse to:
- Notify physician for systolic blood pressure <90 or >160
- Notify physician for diastolic blood pressure >100
- Notify physician for pulse <55 or >100
- Notify physician for weight gain greater than _____ lb in ____days
- Notify physician for weight loss greater than _____ lb in ____ days
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Skilled Nursing (amount/frequency/duration included)
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Skilled Nursing (amount/frequency/ duration included)
- Option to instruct the home care nurse to:
- Teach patient to monitor daily weights.
- At each visit assess: pulse, blood pressure, weight, heart rate and rhythm, lung sounds, and lower extremities for edema and perfusion.
- Monitor and teach signs and symptoms of worsening heart failure.
- Educate about low sodium diet.
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Safety Measures
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Safety Measures
- Option to instruct the home care nurse to:
- Perform home safety assessment.
- Other (specify).
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Activities Permitted
- Complete bedrest
- Bedrest BRP
- Up as tolerated
- Transfer bed/chair
- Exercise prescribed
- Partial weight bearing
- Independent at home
- Crutches
- Cane
- Wheelchair
- Walker
- No restrictions
- Other (specify)
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Activities Permitted
SAME, with the addition of
- Option to communicate/order:
- No restrictions.
- Assess need for physical therapy evaluation.
- Physical therapy evaluation.
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Durable Medical Equipment
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Durable Medical Equipment
- Option to order:
- Level 1 mattress
- Level 2 mattress
- Hospital bed
- Wheelchair
- Hoyer lift
- Trapeze
- Suction machine
- Home oxygen (liters/min)
- Tub seat
- Commode
- Other(specify)
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Supplies
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Supplies
- Option to instruct the home care nurse to:
- Assess supplies needed
- Other (specify)
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Nutritional Requirements
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Nutritional Requirements
- Option to instruct the home care nurse to:
- Assess nutritional requirements
- Other (specify)
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Orders for Other Discipline and Treatments (amount/frequency/duration included for each |
Home Health Aide
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Home Health Aide
- Option to instruct the home care nurse to:
- Assess need for home health aide.
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Physical Therapy
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Physical Therapy
- Option to instruct the home care nurse to:
- Assess need for physical therapy.
- Option to instruct the therapist to provide specific treatments:
- ADL training
- Chest physical therapy
- Coordination/balance activities
- Establish/upgrade home program
- Gait training
- Prosthetic/orthotic training
- Therapeutic exercises
- Transfer training
- Other specify)
- Option to instruct the therapist to provide specific modalities (locations and parameters included):
- Cryotherapy
- Moist heat
- TENS
- Other (specify)
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Occupational Therapy
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Occupational Therapy
- Option to instruct the home care nurse to:
- Assess need for occupational therapy
- Option to instruct the therapist to provide specific treatments:
- ADL training
- Cognitive training
- Establish/upgrade home program
- Fine motor coordination
- Functional transfer training
- Orthotic/splinting
- Therapeutic exercises
- Visual perceptual training
- Other (specify)
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Speech Therapy
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Speech Therapy
- Option to instruct the home care nurse to:
- Assess need for speech therapy
- Option to instruct the therapist to provide specific treatments:
- Aphasia treatment
- Cognitive communicative treatment
- Dysphagia treatment
- Establish/upgrade home program
- Non-verbal communication training
- Speech/voice disorders treatment
- Other (specify)
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Social Work
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Social Work
- Option to instruct the home care nurse to:
- Assess need for medical social worker
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Audiology
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Audiology
- Option to instruct the home care nurse to:
- Assess need for audiologist
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Discharge Plans |
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- Option to communicate expectations for plans for care after discharge:
- Assisted living
- Care to be provided by family/friends
- Certified agency
- Home attendant service
- Hospice
- Long-term home health program
- Nursing home
- Self-care
- Other(specify)
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Orders for Other Conditions |
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Catheter Care
- Option to instruct the home care nurse to:
- Provide and/or instruct catheter insertion
- Option to communicate details for catheter insertion:
- Straight for:
- Residual
- Voiding
- Specimen
- Type (clean, sterile)
- Foley:
- Suprapubic
- Urethral
- For (retention, incontinence, initial insertion)
- Next change date
- Lumen size
- Balloon size
- Frequency
- Option to instruct the home care nurse to:
- Provide and/or instruct external catheter application (QD & PRN)
- Provide and/or instruct catheter
- Irrigation
- Option to communicate details for catheter irrigation:
- Foley
- Nephrostomy
- Solution (NS, other, amount)
- Frequency
- Option to instruct the home care nurse to:
- Provide and/or instruct catheter care (Foley QD & PRN, external QD & PRN)
Diabetes Care
- Option to instruct the home care nurse to:
Central Line Catheter
- Option to instruct the home care nurse to:
- Flush with NS, followed by heparin 1,000 units weekly.
Wound Care
Orders for up to 3 wounds (location included)
- Option to communicate wound type:
- Surgical (open, closed)
- Neuropathic ulcer
- Pressure ulcer stage (1-4, unable to stage)
- Venous stasis ulcer
- Arterial ulcer
- Arterial/venous stasis mix
- Burn/radiation burn
- Traumatic
- Other wound/lesion etiology (cancerous, dermatological, inflammatory, lymphatic, sickle cell/thalassemia, unknown)
- Option to instruct the home care nurse to:
- Step 1: cleanse, irrigate, soak for ___ minutes
- Solution 1: NS, other
- Step 2: cleanse, irrigate, soak for ___ minutes
- Solution 2: NS, other
- Option to communicate details for packing:
- Alginate
- Foam
- Gauze (dry)
- Gauze hypertonic sodium impregnated/Curasalt™
- Hydrocolloid paste
- Hydrogel impregnated gauze
- Hydrogel liquid/amorphous
- Hydrogel solid sheet/strands
- Packing strips
- Wet to damp NS
- Wet to dry NS
- Other (specify)
- Option to communicate details for primary dressing:
- Alginate
- Foam
- Gauze (dry)
- Gauze hypertonic sodium impregnated/Curasalt™
- Hydrocolloid paste
- Hydrogel impregnated gauze
- Hydrogel liquid/amorphous
- Hydrogel solid sheet/strands
- Transparent
- Wet to damp NS
- Wet to dry NS
- Other (specify)
- Option to communicate details for secondary dressing:
- Foam
- Gauze (dry)
- Gauze wrap
- Hydrocolloid
- Transparent
- Other (specify)
- Option to communicate details for venous stasis/lymphedema compression orders:
- Unna Boot/Viscopaste* and Coban™
- Multiple-layered bandage/Profore™
- ACE® bandage
- Compression stockings
- Other (specify)
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