Appendix B. Sample e-485 Form

Development of Electronic Transition Tools for Home Health Care

HOME HEALTH CERTIFICATION AND PLAN OF CARE
Patient's Name, Address & Emergency Contact	Provider's Name, Address and Telephone Number
Jane Doe 1600 Pennsylvania Street New York, NY 212-200-2002 Emergency: Thomas Jefferson Emergency Phone: 301-300-3001	VNS of New York 5 Penn Plaza New York, NY 10001 212-987-6543
Date of Birth 12/25/1945 Sex □ Male □ Female	Insurance: Policy #: 999999999
A. Diagnoses	Safety Measures Perform Home Safety Assessment DME Tub Seat Home Health Aide Assess need for Home Health Aide Social Work Audiology Physical Therapy Assess for PT Modalities Occupational Therapy Assess for OT Speech Therapy
ICD 427.31 ATRIAL FIBRILLATION ICD 564.09 CONSTIPATION NEC ICD V54.13 AFTRCRE TRAUMATIC FX HIP ICD 781.2 ABNORMALITY OF GAIT ICD 733.00 OSTEOPOROSIS NOS ICD 401.9 HYPERTENSION NOS ICD 402.91 HYPERTENSION HEART DIS W CHF ICD 428.0 CONGESTIVE HEART FAILURE
B. Allergies

C. Functional Limitations
Continence – need assessment Ambulation – Impairment Dyspnea- Impairment
D. Mental Status
Oriented-Person Disoriented-Time Forgetful
E. Prognosis
Prognosis Fair Prognosis is known by family	H. Discharge Plan
Prognosis Fair Prognosis is known by family	Care to be provided by Family/Friends
F. Goals	Wound Care – Wound #1
Patient/caregiver will be knowledgeable about disease; behaviors needed to manage condition; signs and symptoms of complications; prescribed diet; signs and symptoms of 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 will increase participation in ADLs.	Wound Location: sacrum Pressure Ulcer Stage 2 Step 1 Cleanse NS Step 2 Packing Primary Foam Hydrogel Liquid/Amorphous Hydrogel Solid Sheets/Strands Secondary Venous Stasis/Lymphedema Comp
G. Orders	Wound Care – Wound #2
Medication list and monitoring LOPRESOR 50MG TABLET/1 tab po bid CITRACAL + D CAPLET/1 tab po bid ACTONEL 35 MG TABLETS/ 1 tab po qd LASIX 40MG TABLET/ 1 tab po bid WARFARIN 2MG TABLET/take as directed	Step 1 Step 2 Packing Primary Secondary
	Wound Care – Wound#3
□Check for medication adherence □Teach/reinforce roles, side effects, and dosages of medications Medication adjustments Increase enalapril by 5mg each week until pulse is 110/70 Physician notification Notify physician for Systolic BP is < 90 or > 160 Notify physician for Diastolic BP is > 100 Notify physician for Pulse < 55 or > 100 Notify physician for weight gain greater than 3 lbs in 3 days Nurse Treatments Educate about low sodium diet Activities permitted No Restrictions	Step 1 Step 2 Packing Primary Secondary
Nurse Signature and Date of Verbal SOC Where Applicable	Date HHA Received Signed POT
Physician's Name and Address Dr. Dolittle	I certify that this patient is confined to his/her home and needs intermittent skilled nursing care, physical therapy and/or speech therapy or continues to need occupational therapy. The patient is under my care, and I have authorized the services on this plan of care and will periodically review the plan.
Attending Physician's Signature and Date Signed 12/04/04	Anyone who misrepresents, falsifies, or conceals essential information required for payment of Federal funds may be subject to fine, imprisonment, or civil penalty under applicable Federal laws.

Note: Patient information in the sample above is fictitious.

Current as of September 2007

Internet Citation: Appendix B. Sample e-485 Form: Development of Electronic Transition Tools for Home Health Care . September 2007. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/hcbs/etransitions/etransitionsapb.html