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The encounter of this patient was in whole or in part for the
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following Medical condition(s), which is the primary reason
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for REFERRAL to Home Health Services.
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(List Medical Condition(s)):
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Diagnosis -->
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Dx Values:
• • •
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Dx Free Text
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*Other Diagnosis -->
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Other Dx Values:
• • •
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Other Dx Free Text
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I Certify Eligibility for Home Health
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Admit to Home Health
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Comments:
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Skilled Nursing
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Justification:
• • •
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Other Comments:
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Teach patient/family/caregiver
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Physical Therapy
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Justification:
• • •
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Other Comments:
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Speech Therapy
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Justification:
• • •
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Other Comments:
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Occupational Therapy
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Justification:
• • •
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Other Comments:
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Medical Social Worker
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Justification:
• • •
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Other Comments:
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Home Health Aide
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Justification:
• • •
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Other Comments:
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Criteria 1: The patient must either:
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1.) Because of illness or injury, need
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for supportive device(s)
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such as: -->
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Such as:
• • •
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due to: -->
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Due to:
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2.) Have condition such that leaving
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his/her home is medically contraindicated
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a.) Shortness of breath
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✓ Shortness of breath
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✓ With minimal exertion
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b.) Supportive devices / assistance required
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✓ Supportive devices / assistance required
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c.) Supplemental O2
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✓ Supplemental O2
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d.) Ambulation difficulty
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Ambulation difficulty due to:
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Due to:
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Due to:
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e.) others
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Others
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Due to:
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Due to:
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f.) Psychiatric Condition prevents pt leaving home
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Psychiatric Condition prevents pt leaving home
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Related to:
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Related to:
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Criteria 2: There must exist both
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1.) A normal inability to
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leave home.
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Values: -->
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*Values
• • •
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Related to (diagnosis as above): -->
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*Type Here (Related to)
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2.) Exertion of a considerable and taxing
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effort is needed to leave home because:
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a.) Patient conditions and symptoms are:
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*Type Here (Conditions and Symptoms)
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b.) Weakness as evidenced by:
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*Type Here (Weakness as evidenced by)
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Patient has these symptoms
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a.) Increase pain
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Increase pain
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- location:
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Type Here (location values)
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b.) Frequent restrooms
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Frequent restrooms
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- related to:
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related to:
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c.) SOB
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SOB
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- related to:
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related to:
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d.) Fall Risk
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Fall risk
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- related to:
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related to:
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e.) Others
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Other, Describe:
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- describe:
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describe:
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