Is this assessment for an "early" or "later" episode in this sequence of Medicare episodes?

checked > 1 - Early checked > 2 - Later checked > UK - Unknown checked > NA - Not Applicable:no Medicare case mix group to be defined

M1021/3/5 ICD

and Severity Index: List up to 6 ICDs for which the patient is receiving home care and rate them using the severity index.

New treatments/interventions for this assessment

Delete Selected

new/changed medications

Why are we top

M1200 Vision (with corrective lenses if the patient usually wears them)

checked> Normal vision: Sees adequately in most situations; can see medication labels, newsprint checked> Partially impaired: cannot see medication label or newsprint but can see obstacles on path checked> Severely impaired: cannot locate objects without hearing or touching them or patient nonresponsive

M1242 Frequency of Pain Interfering with patient's activity or movement

checked /> 0 - Patient has no pain
checked /> 1 - Patient has pain that does not interfere with activity or movement
checked /> 2 - Less often than daily
checked /> 3 - Daily, but not constantly
checked /> 4 - All of the time

Pain Assessment

Skin Assessment

checked type="checkbox" value="Poor skin turgor" onclick="changebg('color','txtSkinOther','divskin');"/> Poor skin turgor checked value="Color pale" onClick="changebg('color','txtSkinOther','divskin');"> Color pale checked value="Color jaundice" onClick="changebg('color','txtSkinOther','divskin');" /> Color jaundice checked value="Color cyanotic" onClick="changebg('color','txtSkinOther','divskin');" /> Color cyanotic checked value="Sweaty skin" onClick="changebg('color','txtSkinOther','divskin');" /> Sweaty skin

checked value="Dry skin" onClick="changebg('color','txtSkinOther','divskin');" /> Dry skin checked value="Bruise(s)" onClick="changebg('color','txtSkinOther','divskin');" /> Bruise(s) checked value="Rash(es)" onClick="changebg('color','txtSkinOther','divskin');" /> Rash(es) checked value="Asymptomatic" onClick="changebg('color','txtSkinOther','divskin');" /> Asymptomatic checked value="Other" onClick="changebg('color','txtSkinOther','divskin');" /> Other

M1306 Does this patient have at least one Unhealed Pressure Ulcer at Stage ll or Higher or designates as "unstageable"?

checked> 0 - No checked> 1 - Yes

a. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough.

*number currently present

**number of those currently present that were also present at SOC/ROC

b. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed.

c. Stage 4: Full thickness tissue loss with visible bone, tendon, or muscle.

d.1. Unstageable: due to non-removable dressing or device

d.2. Unstageable: due to coverage of wound bed by slough and/or eschar.

d.3. Unstageable: Suspected deep tissue injury evolution.

M1322 Current Number of Stage I Presure Ulcers: Intact skin with non-blanchable redness over a bony area. May be a painful, firm, soft, warmer or cooler.Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues.

checked> 0 - Zero checked> 1 - One checked> 2 - Two checked> 3 - Three checked> 4 - Four or more

M1324 Stage of Most Problematic (Observable) Pressure Ulcer

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 Stasis Ulcer?

checked> 0 - No checked> 1 - Yes, patient has BOTH observable and unobservable stasis ulcers checked> 2 - Yes, patient has observable stasis ulcers ONLY checked> 3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing)

M1332 CurrentNumber of Observable Stasis Ulcer(s)

checked> 0 - Zero checked> 1 - One checked> 2 - Two checked> 3 - Three checked> 4 - Four or more

M1334 Status of Most Problematic (Observable) Stasis Ulcer

checked> 0 - Newly epithalialized checked> 1 - Fully granulating checked> 2 - Early/partial granulation checked> 3 - Not healing

M1340 Does patient have a Surgical Wound?

checked> 0 - No checked> 1 - Yes, patient has at least one (observable) surgical wound checked> 2 - Surgical wound known or likely but not observable due to non-removable dressing

M1342 Status of Most Problematic (Observable) Surgical Wound

checked> 0 - Newly epithalialized checked> 1 - Fully granulating checked> 2 - Early/partial granulation checked> 3 - Not healing

M1350 Does patient have a Skin Lesion or Open Wound excluding bowel ostomy other than those described above receiving intervention

checked> 0 - No checked> 1 - Yes

M1400 When is the patient dyspneic or noticeably short of Breath?

checked> 0 - Never, patient is not short of breath checked> 1 - When walking more than 20 feet, climbing stairs checked> 2 - With moderate exertion checked> 3 - With minimal exertion or with agitation checked> 4 - At rest (during day or night)

M1610 Urinary incontinence or urinary Catheter Presence

checked> 0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) checked> 1 - Patient is incontinent checked> 2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)

M1620 Bowel incontinence Frequency

checked> 0 - Very rarely or never has bowel incontinence checked> 1 - Less than once weekly checked> 2 - One to three times weekly checked> 3 - Four to six times weekly checked> 4 - On a daily basis checked> 5 - More often than once daily checked> NA - Patient has ostomy for bowel elimination checked> UK - Unknown

M1630 Ostomy for Bowel Elimination: Doees pt have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatientfacility stay, or b) necessitated a change in medical or treatment regimen?

checked> 0 - Patient does not have an ostomy for bowel elimination checked> 1 - Patient's ostomy was not related to an inpatient stay and did not necessitate change in regimen checked> 2 - The ostomy was related to an inpatient stay or did necessitate change in regimen

M1810 Ability to Dress Upper Body including undergarments pullovers, front-opening shirts and blouses, managing zippers, buttons...

checked> 0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance checked> 1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient checked> 2 - Someone must help the patient put on upper body clothing checked> 3 - Patient depends entirely upon another person to dress the upper body

M1820 Ability to Dress Lower Body including undergarments, stacks, socks or nylons, shoes.

checked> 0 - Able to obtain, put on, and remove clothing and shoes without assistance checked> 1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient checked> 2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes checked> 3 - Patient depends entirely upon another person to dress lower body

M1830 Bathing: Ability to wash entirebody. (Excludes grooming).

checked> 0 - Able to bath self in shower or tub independently, including getting in and out tub/shower checked> 1 - With the use of devices, is able to bath self in shower or tub independently, including getting in and out of the tub/shower checked> 2 - Able to bath in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of shower or tub, OR (c) for washing difficult to reach areas checked> 3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision checked> 4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode checked> 5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath checked> 6 - Unable to participate effectively in bathing and is bathed totally by another person

M1840 Toilet Transfering: Ability to get to and from the toilet or bedside commode.

checked> 0 - Able to get to and from the toilet and transfer independently with or without a device checked> 1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer checked> 2 - Unable to get to and from the toilet but is able to use a bedside commode (with or without assistance) checked> 3 - Unable to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently checked> 4 - Is totally dependent in toileting

M1850 Transferring: Ability to move from bed to chair,on & off toilet or commode,into and out of tub or shower,and ability to turn and...

checked> 0 - Able to independently transfer checked> 1 - Transfers with minimal human assistance or with use of an assistive device checked> 2 - Unable to transfer self but is able to bear weight and pivot during the transfer process checked> 3 - Unable to transfer self and is unable to bear weight or pivot when transferred by another person checked> 4 - Bedfast, unable to transfer but is able to turn and position self in bed checked> 5 - Bedfast, unable to transfer and is unable to turn and position self

M1860 Ambulation: Ability to SAFELY walk, once in a standing position or use a wheelchair, once in a seated position, on a variety...

checked> 0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device) checked> 1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings checked> 2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces checked> 3 - Able to walk only with the supervision or assistance of another person at all times checked> 4 - Chairfast, unable to ambulate but is able to wheel self independently checked> 5 - Chairfast, unable to ambulate and is unable to wheel self checked> 6 - Bedfast, unable to ambulate or be up in a chair

M2030 Management of Injectable Medications: patient's Current ability to prepare and take all prescribed injectable medications reliably and safely,including administration of corrent dosage at the appropriate time/intervals. Excludes IV medications.

checked> 0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times checked> 1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart checked> 2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection checked> 3 - Unable to take injectable medication unless administered by another person checked> NA - No injectable medications prescribed

M2200 - Therapy Need: in the home health plan of care for the medicare payment episode for which this assessment will define a case mix group,what is the indicated need for therapy visits (total of reasonable and necessary physical, occupational,and speech-language pathology visits combined)?(Enter Zero ["000"] if no therapy visits indicated.)

value="#Recertform.M0826_Ther_Need#"value="0" maxlength="3">

total therapy visits

NA - Not Applicable checked> NA - Not Applicable

waiting for evaluation?

Yes checked> Yes

M0090 Date Completed

Date Format: mm/dd/yyyy

M0110 Episode Timing

Braden Scale For Predicting Pressure Sore Risk

#Getpatient.First_Name_M0040# #Getpatient.Last_Name_M0040# 1 - Start of Care, Not Complete