SELECT Assessment_Forms.Assessment_Forms_ID, Assessment_Forms.Assessment_Tracker_ID, Assessment_Forms.Assessment_Number, Assessment_Forms.Patient_ID, Assessment_Forms.Agency_ID, Assessment_Forms.Form_Type, Assessment_Forms.Record_Num, Assessment_Forms.Record_Creation_Date, Assessment_Forms.Record_Mod_date, Assessment_Forms.Date_sent, Assessment_Forms.HI_Claim_Item_1, Assessment_Forms.SOC_Item_2, Assessment_Forms.Cert_start_Item_3a, Assessment_Forms.Cert_End_Item_3b, Assessment_Forms.Medical_Num_Item_4, Assessment_Forms.Provider_Num_Item_5, Assessment_Forms.Name_Item_6, Assessment_Forms.Provider_name_Item_7, Assessment_Forms.DOB_Item_8, Assessment_Forms.Gender_Item_9, Assessment_Forms.Active_meds_Item_10, Assessment_Forms.M0230_ICD_Item_11, Assessment_Forms.M0230_Diagnosis_Item_11, Assessment_Forms.M0230_Date_Item_11, Assessment_Forms.Surgical_ICD_Item_12, Assessment_Forms.Surgical_Procedure_Item_12, Assessment_Forms.Surgical_Procedure_Date_Item_12, Assessment_Forms.M0240_ICD_Item_13, Assessment_Forms.M0240_Diagnosis_Item_13, Assessment_Forms.M0240_Date_item_13, Assessment_Forms.DME_Supplies_Item_14, Assessment_Forms.Safety_Measures_Item_15, Assessment_Forms.Nutritional_Item_16, Assessment_Forms.Allergies_Item_17, Assessment_Forms.Func_Limits_Item_18a_other, Assessment_Forms.Func_Limits_item_18a, Assessment_Forms.Activities_Permitted_Item_18b, Assessment_Forms.Activities_Permitted_Item_18b_Other, Assessment_Forms.Mental_Status_Item_19, Assessment_Forms.Mental_Status_Item_19_Other, Assessment_Forms.Prognosis_Item_20, Assessment_Forms.Order_item_21, Assessment_Forms.Goals_Item_22, Assessment_Forms.Physician_Item_24, Assessment_Forms.Date_Received_Item_25, Assessment_Forms.Form_Status, Assessment_Forms.Physician_ID, Assessment_Forms.Physician_Email_Sent, Assessment_Forms.Physician_Comments, Assessment_Forms.Addendum_Num_10, Assessment_Forms.Addendum_Num_21, Assessment_Forms.Addendum_Num_22, Assessment_Forms.Addendum_Details_10, Assessment_Forms.Addendum_Details_21, Assessment_Forms.Addendum_Details_22, Assessment_Forms.Record_Modified_By, Assessment_Forms.Discharge, Assessment_Forms.SN_Schedule_21, Assessment_Forms.Therapy_Schedule_21, Assessment_Forms.HHA_Schedule_21, Assessment_Forms.Digital_Signature, Assessment_Forms.Record_Created_By, Assessment_Forms.Nurse_Digital_Signature, Assessment_Forms.unarchive, Assessment_Forms.contact_id, Assessment_Forms.Phys_Descr_Homebound, Assessment_Forms.Phys_Descr_Clinical_Cond, Assessment_New.Physician_Last_Seen_Date,patient.Location FROM #Request.prefix_db_agency#.Assessment_Forms JOIN #Request.prefix_db_agency#.Assessment_New on Assessment_Forms.Assessment_Tracker_ID = Assessment_New.Assessment_Tracker_ID JOIN #Request.prefix_db_agency#.patient on Assessment_New.Patient_ID = patient.Patient_ID WHERE Assessment_Forms.Assessment_Forms_ID = '#url.afId#' 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, SN_Visit_Orders, Therapy_Schedule, Therapy_Visit_Orders, HHA_Schedule, HHA_Visit_Orders, Rehab_Prognosis_M0270, 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 #Request.prefix_db_agency#.Assessment_New WHERE Assessment_ID = '#Form.Assessment_Number#' ORDER BY Assessment_Completed_M0090 Desc Select Start_of_Care_M0030 from #Request.prefix_db_agency#.Assessment_New where Assessment_ID=(select Assessment_Number from #Request.prefix_db_agency#.Assessment_Forms where Assessment_Forms_ID='#url.afId#') Select Agency_Name, Agency_Address1, Agency_City, Agency_State, Agency_Zip, Natl_Provider_ID, Agency_Contact_Phone, Agency_Fax from #Request.prefix_db_lookup#.Agency where Agency_ID='#session.AgencyID#' SELECT * FROM #Request.prefix_db_agency#.Locations WHERE Location_ID = '#Form.Location#' Select Skill from #Request.prefix_db_lookup#.Employee where Employee_ID='#session.EmployeeId#'

Department of Health and Human Services Form Approved Health Care Financing Administration OMB No. 0938-0357

INTERDISCIPLINARY TEAM - HOSPICE PLAN OF CARE

1. Patient's HI claim No.		2. Start Of Care Date		3. Certification Period					4. Medical Record No.		5. Provider No.
#Form.HI_Claim_Item_1#		#DateFormat(Form.SOC_Item_2,"mm/dd/yyyy")#		From:	#DateFormat(Form.Cert_start_Item_3a,"mm/dd/yyyy")#	To:	#DateFormat(Form.Cert_End_Item_3b,"mm/dd/yyyy")#		#Form.Medical_Num_Item_4#		#Form.Provider_Num_Item_5#

' & 'telephone ' & #Get_location.Agency_Contact_Phone#&' fax '&#Get_location.Agency_Fax#> ' & 'telephone ' & #formagency.Agency_Contact_Phone#&' fax '&#formagency.Agency_Fax#>

6. Patient's Name and Address	7. Provider's Name, Address and Telephone Number
#ListElement#	#ListElement#

#M0230diag#
---> select group_concat(Short_Diagnosis separator '&') as data from #Request.prefix_db_agency#.Diagnosis where assessment_id=(select Assessment_Number from #Request.prefix_db_agency#.Assessment_Forms where Assessment_Forms_ID='#url.afId#')and Primary_Diagnosis<>1 and M0230_Link<> 'null'; select Left(Short_Diagnosis,25), ICD from #Request.prefix_db_agency#.Diagnosis where assessment_id=(select Assessment_Number from #Request.prefix_db_agency#.Assessment_Forms where Assessment_Forms_ID='#url.afId#')and Primary_Diagnosis<>1 and M0230_Link<> 'null';

8. Date

#DateFormat(Form.DOB_Item_8,"mm/dd/yyyy")#

9.Sex

#Form.Gender_Item_9#

11. ICD

Principal Diagnosis

Date

#Form.M0230_ICD_Item_11#

#Left(Form.M0230_Diagnosis_Item_11,25)#

#DateFormat(Form.M0230_Date_Item_11,"mm/dd/yyyy")#

#DateFormat(date11,"mm/dd/yyyy")#

12. ICD

Surgical Procedure

Date

#ICD9CM1#

#surgicalpro#

#DateFormat(date12,"mm/dd/yyyy")#

13. ICD

Other Pertinent Diagnoses

Date

#ListElement#

#Replace(ListElement, ",", "", "ALL")#

#DateFormat(date13,"mm/dd/yyyy")#

10. Medications: Dose/Frequency/Route (N)ew (C)hanged

#Activemeds#

14. DME and Supplies:	15. Safety Measures:
#replace('#Form.DME_Supplies_Item_14#',',',', ',"ALL")#	#replace('#Form.Safety_Measures_Item_15#',',',', ',"ALL")#

16. Nutrition Required:

#replace('#Form.Nutritional_Item_16#',',',', ',"ALL")#

17. Allergies:

#Form.Allergies_Item_17#

18.A. Functional Limitations

[ X ] Amputation	[ X ] Ambulation

[ X ] Bowel/Bladder(Incontinence)	[ X ] Speech

[ X ] Contracture	[ X ] Legally Blind

[ X ] Hearing	[ X ] Dyspnea W Min Exertion

[ X ] Paralysis	[ X ] Other: #Form.Func_Limits_Item_18a_other#

[ X ] Endurance

18.B. Activities Permitted

[ X ] Complete Bedrest	[ X ] Independent At Home	[ X ] Other: #Form.Activities_Permitted_Item_18b_Other#

[ X ] Bedrest BRP	[ X ] Crutches

[ X ] Up As Tolerated	[ X ] Cane

[ X ] Transfer Bed/Chair	[ X ] Wheelchair

[ X ] Exercises Prescribed	[ X ] Walker

[ X ] Partial Weight Bearing	[ X ] No Restrictions

19. Mental Status:

[ X ] Oriented	[ X ] Forgetful	[ X ] Disoriented	[ X ] Agitated

[ X ] Comatose	[ X ] Depressed	[ X ] Lethargic	[ X ] Other: #Form.Mental_Status_Item_19_Other#

20. Prognosis:

[ X ] Poor

[ X ] Guarded

[ X ] Fair

[ X ] Good

[ X ] Excellent

21. Orders for Discipline and Treatments(Specify Amount/Frequency/Duration)

Therapy Visit Schedule' or #Form.Order_item_21# contains '
HHA Visit Schedule'> #Trim(Form.Order_item_21)# SN_Schedule: #Trim(GetAssessDet.SN_Visit_Orders)#
Therapy_Schedule: #Trim(GetAssessDet.Therapy_Visit_Orders)#
HHA_Schedule: #Trim(GetAssessDet.HHA_Visit_Orders)#

#order_item#

22. Goals/Rehabilitation Potential/Discharge Plans

#Trim(Replace(Form.Goals_Item_22, CrLf, "
", "ALL"))#
Rehabilition Potential:#GetAssessDet.Rehab_Prognosis_M0270#
Discharge Plans:#Form.Discharge#

23. Signature and Date of Verbal SOC Where Applicable:		25. Date HHA Received Signed POT
#Form.Nurse_Digital_Signature#		#DateFormat(Form.Date_Received_Item_25,"mm/dd/yyyy")#

24. Physician's Name and Address

#Address#
#ListElement#

26.	I certify that this patient is terminally ill and has a life expectancy of six (6) months or less if the disease follows its normal course. The patient is under my care,and I have authorized the services on this plan of care and will periodically review the plan.

27. Attending Physician's Signature and Date Signed #DateFormat(Form.Physician_Last_Seen_Date,"mm/dd/yyyy")#: Date of physician last face-to-face

DIGITALLY SIGNED BY #Form.Digital_Signature#

28.	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.

TO ATTENDING PHYSICIAN: PLEASE DOCUMENT THE FOLLOWING

Clinical conditions causing the patient to be homebound: #Form.Phys_Descr_Homebound#________________________________________________________

Clinical conditions causing the patient to require skilled home health: #Form.Phys_Descr_Clinical_Cond#________________________________________________________

Form CMS-485 (C-3) (02-94) (Print Aligned)

PROVIDER

ADDENDUM TO: [X] PLAN OF TREATMENT [ ] MEDICAL UPDATE

1. Patient's HI claim No.		2. Start Of Care Date		3. Certification Period					4. Medical Record No.		5. Provider No.
#Form.HI_Claim_Item_1#		#DateFormat(Form.SOC_Item_2,"mm/dd/yyyy")#		From:	#DateFormat(Form.Cert_start_Item_3a,"mm/dd/yyyy")#	To:	#DateFormat(Form.Cert_End_Item_3b,"mm/dd/yyyy")#		#Form.Medical_Num_Item_4#		#Form.Provider_Num_Item_5#

6. Patient's Name and Address	7. Provider's Name, Address and Telephone Number
#ListElement#	#ListElement#

MEDICATIONS cont:
#Trim(Replace(Form.Addendum_Details_10, CrLf, "
", "ALL"))#

ORDERS cont:
#Trim(Replace(Form.Addendum_Details_21, CrLf, "
", "ALL"))#

GOALS/REHAB/DISCHARGE PLANS cont:
#Trim(Replace(Form.Addendum_Details_22, CrLf, "
", "ALL"))#

9. Signature of Physician

10. Date

11. Optional Name/Signature of Nurse/Therapist

12. Date

Form HCFA-485 (C-3) (02-94) (Print Aligned)

PROVIDER