Face-to-Face Progress Note and Home Health Orders

IMPORTANT: For orders to be carried out, you must check the box next to the service needed (services identified by bold letters). Initial certification and orders must be signed and dated by attending physicians. The Home Health Orders portion of the form for resumption of care or an update to the initial certification can be completed by any provider.

Patient Name(Required)

Patient DOB(Required)

Anticipated date of discharge: (applies only to hospital or facility)

Date of Discharge

Attending physician expected to follow patient: (first and last name)

Physician Name

Attending physician phone number:

Physician Number

Face-to-Face Encounter occurred on: (should be within 90 days of start of care)

Date of Encounter

Client Findings

Patient's medical condition or diagnosis of

Patient Diagnosis

results in:

Check all that apply

(specify other)

Homebound Status

Due to the above-stated illness, injury, or surgical procedure (medical condition or diagnosis) and associated clinical findings, the patient is homebound because of his/her inability to leave home except with aid of a supportive device and/of person AND leaving the home requires a considerable and taxing effort or is medically contraindicated.

REQUIRED: Must complete both sections fo this table to meet homebound eligibility criteria.

Patient requires the following assistance to leave the home: (Check all that apply)(Required)

Cane

Walker

Wheelchair

Aid of another person

medically contraindicated

AND (required)

Patient cannot leave the home or requires assistance to leave the home because: (Check all that apply)(Required)

High fall risk due to gait instability

Muscle Weakness

Cognitive deficits impace judgment, impair ability to safely naviate and prevent decision making for safety

Shortness of breath/distress after ambulating more than 10 feet results in high risk for falling

Recent lower/upper extrmity surgical procedure results in instability, weakness, non-weight bearing, and/or pain with ambulation

Patient is bedbound due to:

Other:

(specify why patient is bedbound)

(specify other)

Home Healthcare Orders

Skilled Nursing Order

Skilled Nursing [Check all that apply]

Skilled Nursing List

Medication management (specify):

Anticoagulation

New cardiovascular medications

Diabeties Mellitus Assessment/Teaching

Cardiovascular Cardiopulmonary (CV/CP) Assessment)

Wound Care: (specify wound care and treatment)

Other:

(specify wound care and treatment)

(specify other)

Infusion Therapy Order

Infusion Therapy [Check all that apply]

Infusion Therapy List Item 1

IV medications [ie: antiblotics, chemotherapy, etc.]

Name and dosage:

Frequency and duration:

Type of Line:

Location:

Date

Infusion Therapy List Item 2

TPN [requires a completed TPN Order Form indicating type of formula]

Start Date

Type of Line:

Location:

Date of Insertion

Infusion Therapy List Item 3

Cathflo (Alteplase) 2mg for each occluded lumen, per manufacturer instruction, as needed, while patient is on IV therapy

Infusion Therapy List Item 4

Tube Feeding [requires a completed Tube Feeding Order Form indicating type of formula]

Start Date

Date of Insertion

Type of Tube:

PEG

PEJ

Other

(specify other)

Labs Order

Labs [Check all that apply]

Labs List item

Venipuncture:

PT/INR:

Other Labs:

Venipuncture (specify)

times/week

Untitled

May use PT/INR meter.

Planned date for first INR:

Goal INR Range:

(specify type and frequency)

Therapy Orders

Therapy Orders [Check all that apply]

Therapy List 1

Physical Therapy

PT assess for OT

Occuptional Therapy
(must have skilled nursing or PT ordered)

Speech Language Pathology

Therapy List 2

Provide gait training, strengthening and/or balance exercises to restore the patient's ability to walk safely without pain.

Increase strength and endurance and restore ROM:

Evaluate for assistive devices and/or environmental modifications needed to address ADL deficits to imporve safety with transfers and ambulation.

Teach the patient caregiver compensatory strategies for cognitive deficits.

Teach patient caregiver compensatory environmental modifications for safety.

Evaluate and treat dysphagia.

Evaluate and treat aphagia.

Provide maintenance therapy to prevent or slow a decline in condiition.

Other:

ROM s/p _____________ surgery

(specify other)

Medical Social Worker Order

Medical Social Worker [Must also have skilled nursing, physical therapy or speech therapy ordered]

Home Health Aide Order

Home Health Aide [Not PCA service; must also have skilled nursing, physical therapy or speach therapy ordered]

Full Name

NPI#:

Time

Phone

Digital Signature

Date

NOTE: Initial certification and order must be signed and dated by attending physicians. The home health orders portion of the form for resumption of care or an update to the initial certification can be completed by any provider.

CAPTCHA