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 ContactProvider'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   □ FemaleInsurance: Policy #: 999999999
A. DiagnosesSafety 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
Care to be provided by Family/Friends
F. GoalsWound 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. OrdersWound 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 ApplicableDate 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 12/04/04Anyone 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