SELECT Assessment_New.Start_of_Care_M0030, Assessment_New.Surgical_ICD_485, Assessment_New.Surgical_ICD_Date_485, Assessment_New.Surgical_ICD_485_Description, Assessment_New.Discharged_From_M0175, Assessment_New.Inpatient_Discharge_Date_NA_M0180, Assessment_New.Medical_or_Treatment_Change_M0200, Assessment_New.Conditions_Prior_M0220, Assessment_New.Therapies_Home_M0250, Assessment_New.Overall_Prognosis_M0260, Assessment_New.Transferring_M0690p, Assessment_New.Life_Exp_M0280, Assessment_New.High_Risk_Factors_M0290, Assessment_New.Vision_M0390, Assessment_New.Hearing_M0400, Assessment_New.Speech_M0410, Assessment_New.Freq_of_Pain_M0420, Assessment_New.Intrac_Pain_M0430, Assessment_New.Open_Wounds_M0440, Assessment_New.Pressure_Ulcer_M0445, Assessment_New.Pressure_Ulcer_a_M0450, Assessment_New.Pressure_Ulcer_b_M0450, Assessment_New.Pressure_Ulcer_c_M0450, Assessment_New.Pressure_Ulcer_d_M0450, Assessment_New.Pressure_Ulcer_e_M0450, Assessment_New.Pressure_Ulcer_Stage_M0460, Assessment_New.HHRG_825_Score, Assessment_New.Pressure_Ulcer_Status_M0464, Assessment_New.Stasis_Ulcer_M0468, Assessment_New.Stasis_Ulcer_Num_M0470, Assessment_New.Stasis_Ulcer_Hidden_M0474, Assessment_New.Stasis_Ulcer_Status_M0476, Assessment_New.Surgical_Wound_M0482, Assessment_New.Breathing_M0490, Assessment_New.UTI_M0510, Assessment_New.Urinary_INcont_when_M0530, Assessment_New.Ostomy_for_Bowel_M0550, Assessment_New.When_Confused_M0570, Assessment_New.Depressive_Feelings_M0590, Assessment_New.Patient_Behav_freq_M0620, Assessment_New.Psy_Nursing_M0630, Assessment_New.Grooming_M0640, Assessment_New.Grooming_M0640p, Assessment_New.Dress_Upper_M0650, Assessment_New.Dress_Upper_M0650p, Assessment_New.Dress_Lower_M0660, Assessment_New.Dress_Lower_M0660p, Assessment_New.Bathing_M0670, Assessment_New.Bathing_M0670p, Assessment_New.Toileting_M0680, Assessment_New.Toileting_M0680p, Assessment_New.Rehab_Prognosis_M0270, Surgical_Wound_Hidden_M0486, Breathing_M0490, UTI_M0510, Urinary_INcont_when_M0530, Ostomy_for_Bowel_M0550, When_Confused_M0570, Depressive_Feelings_M0590, Patient_Behav_freq_M0620 FROM #Request.prefix_db_agency#.Assessment_New WHERE Assessment_New.Assessment_ID='#session.cs.AssessmentId#' Select Severity, Primary_Diagnosis, Secondary_Diagnosis from #Request.prefix_db_agency#.Diagnosis where Assessment_ID='#session.cs.AssessmentId#'

Diagnoses/CPT

Start Of Care Date

Add up to

six (6)
diagnoses
and rate them using
the severity index.

Diagnosis	Sev	Prim	Sec
Diabetes mellitus without mention of

Add 1 Procedure

Code		Date		Surgical Procedure

Home Safety

Mark all that apply

checked/>Unsafe stairs and/or doorways
checked />Rugs, cords and/or furniture causing safety risk
checked />Inadequate heating and/or cooling
checked />Unsafe appliances
checked />Inadequate sanitation and/or plumbing
checked/>Inadequate refrigeration
checked/>Presence of insects and/or rodents
checked/>Inadequate smoke detectors
checked/>O2 in use without precautions
checked />Asymptomatic
checked />Other...

Gross Motor ADLs

Bathing

checked /> 0 Dependent: patient does not participate; needs total assist
checked />1 Maximum assist: patient does 25perc of work but needs max support
checked />2 Moderate assist: patient does 50perc of work but needs mod support
checked />3 Minimal assist - patient does 75perc of work but needs light support
checked />4 Contact guard: hold on to the patient
checked />5 Stand-by assistance or supervision
checked />6 Independent

Toileting

checked/> 0 Dependent: patient does not participate; needs total assist
checked/>1 Maximum assist: patient does 25perc of work but needs max support
checked/> 2 Moderate assist: patient does 50perc of work but needs mod support
checked/> 3 Minimal assist - patient does 75perc of work but needs light support
checked/> 4 Contact guard: hold on to the patient
checked/>5 Stand-by assistance or supervision
checked/>6 Independent

Transferring

checked/> 0 Dependent: patient does not participate; needs total assist
checked/>1 Maximum assist: patient does 25perc of work but needs max support
checked/> 2 Moderate assist: patient does 50perc of work but needs mod support
checked/> 3 Minimal assist - patient does 75perc of work but needs light support
checked/> 4 Contact guard: hold on to the patient
checked/>5 Stand-by assistance or supervision
checked/>6 Independent

Ambulation

checked/> 0 Dependent: patient does not participate; needs total assist
checked />1 Maximum assist: patient does 25perc of work but needs max support
checked/> 2 Moderate assist: patient does 50perc of work but needs mod support
checked/> 3 Minimal assist - patient does 75perc of work but needs light support
checked/> 4 Contact guard: hold on to the patient
checked/>5 Stand-by assistance or supervision
checked/>6 Independent

Bed Mobility

Rolls to side
lying position right

Rolls to side
lying position left

Rolls prone to
supine

Rolls supine to
prone

Sits up and
maintains balance

Transfers

Bed

Toilet

Chair-Wheelchair

Bath-Shower

Automobile

To & From Floor

Balance/Gait

Sitting

Standing

Berg Score

Tinetti Score

Gait Surface

Distance

TUG Test