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SELECT patient.*,Agency.* FROM patient, Agency WHERE patient.Patient_Id = '#session.cs.patientid#' AND Agency.Agency_Id = patient.Agency_Id SELECT StateName, StateAbbr FROM States ORDER BY StateName SELECT Physician.Employee_Id,Physician.Physician_Id,Employee.Last_Name as LastName, Employee.First_Name as FirstName, Physician.Natl_Provider_ID,Employee.Address1,Employee.City,Employee.State,Employee.Zip,Employee.Home_Phone, Physician.Fax FROM patient, Physician, Employee WHERE patient.Patient_Id = '#session.cs.patientid#' AND patient.Agency_Id = '#session.AgencyId#' AND Employee.Employee_Id = Physician.Employee_Id AND Physician.Physician_Id = '#GetPatient.Primary_ReferringPhys_ID_M0072#' AND Employee.employeetype='physician' SELECT Assessment_ID, Assessment_Number, Start_of_Care_M0030, Admission_Status, Assessment_Reason_M0100, Assessment_Completed_M0090, Assessment_Tracker_ID, Certification_Start, Certification_End FROM Assessment_New WHERE Patient_Id = '#session.cs.patientid#' AND Admission_Status like 'Complete%' AND Certification_Start <> '0000-00-00' AND Certification_End <> '0000-00-00' AND Deleted <> 1 ORDER BY Assessment_Completed_M0090 Desc SELECT Assessment_ID, Assessment_Number, Start_of_Care_M0030, Admission_Status, Assessment_Reason_M0100 ,Assessment_Completed_M0090, Assessment_Tracker_ID, Certification_Start, Certification_End,Surgical_ICD_485, Surgical_ICD_485_Description, Surgical_ICD_Date_485, SN_Schedule, Therapy_Schedule, HHA_Schedule, DME_485, Safety_measures_485, Func_limitations_485, Func_Limitations_485_Other, Activities_permitted_485, Activities_permitted_485_other, Mental_Status_485, Mental_Status_485_other, Prognosis_485, Nutrition_485, Discharge_485, Goals_485, Form_485_SOC_Date, Form_485_Cert_Start_Date, Form_485_Cert_End_Date, Treatment_Orders FROM Assessment_New WHERE Assessment_ID = '#url.assid#' ORDER BY Assessment_Completed_M0090 Desc SELECT ICD, Short_Diagnosis FROM Diagnosis WHERE Assessment_ID = '#url.assid#' AND M0230_Link is not null AND Primary_Diagnosis = 1

485 Data Collection

There is no physician

Start of Care Date	<cfoutput>#session.cs.patientid#</cfoutput>
Physician	First Name : #GetPatientPhysician.FirstName# Last Name : #GetPatientPhysician.LastName# NPI : #GetPatientPhysician.Natl_Provider_ID# Address : #GetPatientPhysician.Address1# City : #GetPatientPhysician.City# State : #GetPatientPhysician.State# Select State... SELECTED>#getST.StateName# Zip : #GetPatientPhysician.Zip# Phone : #GetPatientPhysician.Home_Phone# Fax : #GetPatientPhysician.Fax#
SN Schedule	<cfoutput>#GetAssessDet.SN_Schedule#</cfoutput>
Skilled Nursing Speech Therapy Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Physical Therapy Medical Social Services Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Occupational Therepy Home Health Aide Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9
Therapy Schedule	<cfoutput>#GetAssessDet.Therapy_Schedule#</cfoutput>
HHA Schedule	<cfoutput>#GetAssessDet.HHA_Schedule#</cfoutput>
DME and Supplies	<cfoutput>#GetAssessDet.DME_485#</cfoutput>
DME checked>4 Wheeled walker checked>long leg brace checked>AFL checked>nebulizer checked>bath bench checked>ostomy supplies checked>cane checked>oxygen supplies checked>commode checked>reacher checked>diabetic supplies checked>rolling walker checked>eggcrate checked>sliding board checked>enema supplies checked>sling checked>feeding pump checked>small base cane checked>feeding tube supplies checked>sock aid checked>grab bars checked>TENs unit checked>hand held shower checked>urinary/catheter supplies checked>hospital bed checked>ventilator and supplies checked>hoyer lift checked>walker checked>IV supplies checked>wheelchair checked>L H. shoe horn checked>wound care supplies checked>L H. sponge checked>Other... checked>large base quad cane #GetAssessDet.DME_485#
Safety Measures	<cfoutput>#GetAssessDet.Safety_measures_485#</cfoutput>
Safety Measures checked>activity supervision checked>no bp right arm checked>ambulates with assistance checked>no constrictive clothing checked>ambulates with devices checked>no lifting checked>anticoagulant precautions checked>no reaching checked>aspiration precautions checked>no stair use checked>avoid temperature extremes checked>no straining checked>bathroom safety checked>non-slip surface in tub checked>bedrails up while in bed checked>non-weight bearing LLE checked>bleeding precautions checked>non-weight bearing RLE checked>cardiac precautions checked>O2 Precautions checked>child-safe environment checked>posey while OOB checked>diabetic precautions checked>remove environmental barriers checked>electrical safety measures checked>restricted ROM checked>emergency phone number prominently displayed checked>seizure precautions checked>fall precautions checked>sharps precautions checked>hand rails checked>smoke detectors checked>hip precautions checked>standard precautions checked>inadequate med/food prep area checked>supervision at all times checked>inadequate medication storage area checked>toe-touch weight bearing LLE checked>infectious material management checked>toe-touch weight bearing RLE checked>knee precautions checked>transfer with assist checked>medical alert/lifeline checked>walker precautions checked>medication safety checked>wheelchair precautions checked>no bending checked>Other... checked>no bp left arm #GetAssessDet.Safety_measures_485#
Nutritional Requirements
Nutrition checked>1000cal ADA checked>high calorie checked>1200cal ADA checked>high fiber checked>1400cal ADA checked>high protein checked>1500cal ADA checked>low cholesterol checked>1800cal ADA checked>low fiber checked>2gm sodium checked>low sodium checked>4gm sodium checked>NG feeding checked>bland checked>pureed checked>cardiac diet checked>regular checked>diabetic checked>renal diet checked>fluid restriction checked>soft checked>fluid for hydration checked>TPN checked>full-liquid checked>vegetarian diet checked>gastrostomy checked>Other... checked>G-Tube #GetAssessDet.Nutrition_485#
Functional Limitations	checked>Amputation checked> Ambulation checked>Bowel/Bladder incontinence checked>Speech checked>Contracture checked>Legally Blind checked>Dyspnea w Min Exertion checked>Hearing checked>Paralysis checked>Other checked>Endurance	Other Functional Limits
Activities Permitted	checked>Complete Bedrest checked> Independent at Home checked> Other checked>Bedrest BRP checked> Crutches checked>Up As Tolerated checked> Cane checked>Transfer bed/chair checked> Wheelchair checked>Exercises Prescribed checked>Walker checked>Partial Weight Bearing checked>No Restrictions	Other Activities Permitted
Mental Status	checked>Oriented checked>Forgetful checked>Disoriented checked>Agitated checked>Comatose checked>Depressed checked>Lethargic checked>Other	Other mental Status
Prognosis	checked>Poor checked>Guarded checked>Fair checked>Good checked>Excellent
Discharge Plans
Discharge Plan checked>care of family checked>day care program checked>discharge not planned checked>homemaker checked>indefinite care checked>nursing home placement checked>Patient/family paying for care indefinitely checked>private duty caregiver checked>self-care checked>self-care with emergency-response system checked>self-care with meals-on-wheels checked>skilled outpatient services checked>terminal condition-discharge not planned checked>Others... #GetAssessDet.Discharge_485#
	If you performed this Yes assessment,do you want to electronically sign the HCFA485?