<cfoutput>#AssForm.Assessment_ID#</cfoutput> M0110 Episode Timing: This is assissment for an "early" or "later" episode?
checked > 1 - Early checked > 2 - Later checked > UK - Unknown checked > NA - Not Applicable:no medicare case mix group to be defined
M1000 From which of the following inpatient facilities was the patient discharged during the past 14 days?(mark all that apply)
M1005 inpatient discharge date:
enter search stringthen click the right onthe diagnosis
delete
M1018 Conditions prior to medical or treatment Regimen change or inpatient stay within past 14 days: if this patient experienced an inpatient facility discharge or change in medical or treatment regimen whitin the past 14 days,indicate any conditions which existed prior tothe inpatient stay or change in medical or treatment regimen(Mark all that apply.)
Home safty Issues Mark all that apply
M1200 Vision with corrective lenses if the Patient usually wears them:
M1210 Ability to heare (with hearing aid or hearing appliance if normally used):
M1220 Understanding of verbal content in patient's own language (with hearing aid or device if used):
M1230 Speech and Oral (verbal) Expression of Language(in patient's own language):
M1240 Has this patient had a formal pain Assessment using a standardized pain assessment tool (appropriate to the patient's ablility to communicate the severity of pain)?
checked> 0-No standardizad assessment conducted checked> 1-Yes,and it does not indicate server pain checked> 2-Yse,and it indicates severe pain
M1242 Frequency of pain interfering with activity/movement
pain assessment indicates #AssForm.M0420_Assess# #AssForm.Pain2# requiring medication every as needed pain relief resolves pain Pain assessment incompleteclick to add
pain assessment indicates #AssForm.M0420_Assess# #AssForm.Pain2# requiring medication every as needed pain relief resolves pain
Pain assessment incomplete
Braden Scale Complete LOW RISK MODERATE RISK HIGH RISK for Pressure Ulcers Pressure Ulcers incomplet click to edit
2 wounds entered-Click to edit
SENSORY PERCEPTION ability to respond meaningfully to pressure-related discomfort
MOISTURE degree to which skin is exposed to moisture
ACTIVITY degree of physical activity
MOBILITY ability to change and control body position
NUTRITION usual food intake pattern
FRICTION & SHEAR
Total Score =#PressureRate# LOW RISK MODERATE RISK HIGH RISK for Pressure Ulcers
checked>0 - Newly epithelialized checked>1 - Fully granulating checked>2 - Earty/partial granulation checked>3 - Not healing checked>NA - No observable pressure ulcer
checked> 0 - Zero checked> 1 - One checked> 2 - Two checked> 3 - Three checked> 4 - Four or more
checked> 1 - Stage I checked> 2 - Stage II checked> 3 - Stage III checked> 4 - Stage IV checked> NA - No observable pressure ulcer or unhealed pressure ulcer
M1330 Does this patient have a Stasis Ulcer?
M1332 Current Number of Observabble Stasis Ulcer(s)
M1334 Status of Most Problematic (Observable)Stasis Ulcer
M1340 Does patient have a Surgical Wound?
M1342 Status of Most Problematic (Observable)Surgical Wound
M1350 Does patient have a Skin Lesion or Open Wound exclusing bowel ostomy other than those described above receiving intervention
M1400 When is the patient dyspneic or noticeably short of Breath?
M1410Respiratory Treatments utilized at home:(Mark all that apply.)
Cardio-Respiratory Hematology
Genitourinary Assessment
M1600 Has pt been treated for urinary Tract infection in past 14 days?
M1610 Urinary incontinence or urinary Catheter Presence
M1615 Urinary incontinence or urinary Catheter Presence
Gastrointestional Assessment
M1620 Bowel incontinence Frequency
Ostomy Assessment
M1630 Ostomy for Cowel estimation : (within the last 14 days): a) was related to an inpatientfacility stay, or b) necessitated a change in medical or treatment regimen?
M1700 Cognitive Functioning: (current level of bootbox.alertness, orientation, comprehension, and immediate memory for simple commands.)
M1710 When Confused (Reported or Observed)
M1730 Depression Screening: Has the patient been screened for depression using a satandardized depression screening tool
PHQ-2 Ask patient :"Over the last two weeks, how often have you been bothered by any of the following problems?"
Little interest or pleasure in doing things?
Felling down, depressedor hopeless?
Neurological Assessment
M1740 Behaviors Demonstrated at Least Once a Week (Reported or Observed): (Mark all that apply.)
M1745 Frequency of Behavior Problems (Reported or Observed) (e.g., Wandering episodes, self abuse, verbal disruption, physical aggression, etc.)
M1750 Is pt receiving Psychiatric Nursing Services at home by a qualified psych. nurse?
#FallRate# HIGH RISK LOW RISK for Falls Fall risk incomplete click to edit
M1800 Grooming: Current ability to tend to personal hygiene needs (i.e., washing face, hair care, shaving/make up, teeth/dentures...
M1810 Currently Ability to Dress Upper Body undergarments pullovers, front-opening shirts and blouses, managing zippers, buttons...
M1820 Currently Ability to Dress Upper Body including undergarments, stacks, socks or nylons, shoes
M1830 Bathing: Current ability to wash entire body.(Excludes grooming).
M1840 Toilet Transfering: Current ability to get to and freom the toilet or bedside commode safely and transfer on and off toilet/commode.
M1845 Toilet Hygiene: Current ability to maintain perineal hygiene safely. If managing ostomy, includes cleaning area around stoma, but not managing equipment...
M1850 Transferring: Current ability to move safety from bed to chair or ability to turn and position self in bed if patient is bedfast.
M1860 Ambulation/Locomotion Ability to walk safely once in a standing position or use wheelchair in a seated position on diff surfaces.
M1870 Feeding or Eating: Current ability to feed self meals and snacks safely. Note: Refers only to process of eating, chewing
M1880 Current Planning and Preparing Light Meals (e.g. cereal, sandwich) or reheat delivered meals safely.
M1890 Ability to use Telephone: Current ability to answer the phone safely including effectively using telephone
M1900 Prior Functioning ADL/ADL: Indicate pt's usual ability with everryday activities prior to this current illness, exacerbation, or injury
Skip M2002 and answer M2010
Skip M2002 - M2030 and answer M2040
Review Meds
M2040 Prior Medication Management Indicate ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.
M2250 Plan of Care Synopsis: Does the physician-ordered plan of care include the following?
vital parameters have been set click to add