PoC

COURVILLE, PAULA (1344017-1) - OASIS - ROC on 10/8/2021

311 Ida St, Eunice, LA 70535-3161

Non-Client Time:

Total Logged Time:

LHC - Resumption of care (after inpatient Stay) (D1) - Approved & Signed- Version 4

Signed By: Romero, Danielle / Date Signed (on paper): 10/8/2021

Approved By: Romero, Danielle / Date Approved: 11/9/2021

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Identification Information

(M0040)

Patient name (Locator #6)

(M0020)

Patient ID number

Certification Period (Locator #3)

From

Vital Signs Readings

Time

RespirationResp.

Blood Pressure

Heart Rate

TemperatureTemp.

Comment

Actions

Home Healthcare to be Provided

Home Healthcare to be Provided In

Patient Home/Residence

Assisted Living Facility

Not Otherwise Specified

Agency Preference

Admission Checklist

Admission Checklist: The Following Instructions/Expectations Were Given to the Patient/Caregiver:

All Consents, Rights and Responsibilities, Were Read to/Explained to the Patient/Caregiver. Understanding Was Verbalized and Copies Were Left In the Home.

Homebound Status Was Met Upon Admission and the Patient/Caregiver Instructed on Homebound Requirements.

Agency Phone Number(s) were given to the patient with instructions on how to reach the agency after hours and on weekends.

"Emergency Preparedness" Information Sheet Was Reviewed With the Patient/Caregiver. Phone Numbers Placed In View.

Patient triaged according to the following (check one)

Category A/Level I: requires services within 24 hours.

Category B/Level II: requires services within 48 hours.

Category C/Level III: services can be postponed for up to 4 days.

Advanced Directives:

No Advanced Directives

Living Will

Health Care Surrogate

Durable Power of Attorney

DNR (MD order required)

Copy of Directive Provided for Medical Record This Visit.

Copy of Directive Requested for Medical Record. Patient/Caregiver Informed Unable to Follow Directive If No Copy Provided. Follow Up Next Visit.

Check

"Home Safety Checklist" Information Sheet Reviewed With The Patient/Caregiver. Verbalized Understanding and Copy Left In Home.

"Pain Management" Information Sheet Reviewed With The Patient/Caregiver. Informed The Patient/Caregiver That The Patient Has The Right to Appropriate Assessment and Management of Pain. Verbalized Understanding and Copy Left In Home.

"Preventing and Controlling Infections" information reviewed with the patient/caregiver. Verbalized understanding and copy left in home.

Disciplines Involved, Visit Patterns, and Discharge Plans Discussed With Patient/Caregiver. Plan of Care Reviewed.

"Call First Procedure" Reviewed, Copy Left In Home for The Patient/Caregiver.

Patient/Caregiver Given Information/Education on Home Oxygen and Fire Safety and Acknowledge That They Will Do Their Best to Replace and Retest Fire Safety Equipment (Extinguishers and Alarms) if They Are Not Adequate, Redesign Their Fire Escape Plans if They Are Not Functional, and Adhere to Oxygen Safety Measures as Applicable.

(M0010)

CMS certification number

(M0014)

Branch state

State:

(M0016)

Branch ID number

Primary Physician

Physician name (Locator #24)

Physician address

Address:
City:
Zip Code:
State:

Physician phone (Locator #24)

Primary Physician Specialty/Contact

Specialty

Contact Person

(M0018)

National Provider Identifier (NPI) for the attending physician who has signed the plan of care
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Physician name
Physician Phone

UK - Unknown or Not Available

Secondary Physicians

Contact Person

(M0030)

Start of care date (Locator #2)

Recent Home Care or Therapy

Is the patient recieving or has recently recieved care from another Home Care or Therapy Clinic

Yes: If Yes, Facility Name: Complete Patient Beneficiaary Form and notify previous Home Heatlh or Outpatient Clinic, as applicable.

(M0032)

Resumption of care date

Patient Address

Address:
City:
Zip Code:
State:

Patient Phone

(M0063)

Medicare number (including suffix)

NA - No Medicare

(M0064)

Social security number

UK - Unknown or Not Available

(M0065)

Medicaid number

UK - NA - No Medicaid

(M0066)

Birth date (Locator # 8)

(M0069)

Gender (Locator #9)

1 - Male

2 - Female

Marital Status

Single

Married

Divorced

Widowed

Other

Private Insurance/Secondary Insurance

Company Name:

Address:

Address:
City:
Zip Code:
State:

Policy #:

Group #:

Telephone:

Contact Person

Long Term Care Policy:

Yes

Policy Holder

Last Name:

First Name:

MI:

Sex:

Relation to Patient:

Secondary Payor

Gravity
Pump, type:		Settings:
IV Push

Infusion Flush Protocol with Medication

Infusion Flush Protocol with Medication

Infusion Flush Protocol without Medication

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Infusion Flush Protocol without Medication

Medication Profile

Medications

Infusions and Oxygen

General

Medbox Details

INTERACTIONS AND ALLERGIES

Drug Allergies

Drug to Drug Interactions

Drug to Food Interactions

Adverse Drug Effects

Duplicate Therapy

Precautions

Plan of Care

Certification Periods and POCs

Current Frequency & Duration Orders

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