Date of Last (Most Recent) Home

Date Format: mm/dd/yyyy

Discharge/Transfer/Death Date

Date Format: mm/dd/yyyy

A2115 Reason For Discharge

checked />1 - Expired checked /> 2 - Revoked checked /> 3 - No longer terminally ill checked /> 4 - Moved out of hospiceservice area checked /> 5 - Transferred to another hospice checked /> 6 - Discharged for cause

Discharge Disposition:Where is the patient after discharge from your agency?

checked /> 1 - Patient remained in the community (without formal assistive services) checked /> 2 - Patient remained in the community (with formal assistive services) checked /> 3 - Patient transferred to a non-institutional hospice checked /> 4 - Unknown because patient moved to a geographic location not served by this agency checked /> UK - Other unknown

Who's caring for patient

Discharge Instructions

Service Utilization

O5000. Level of care in final 3 days
Did the patient receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final 3 days of life?

checked/> 0 - No checked/> 1 - Yes (Skip to Z0400, Signature(s) of Person(s) Completing the Record)

O5010. Number of hospice visits in final 3 days Enter the number of visits provided by hospice staff from the indicated discipline, on each of the dates indicated.

	Visits on day of death (A0270)	Visits one day prior to death(A0270 minus 1)	Visits two day prior to death(A0270 minus 2)
A.Registered Nurse
B.Physician (or Nurse Practitioner or Physician Assistant)
C.Medical Social Worker
D.Chaplain or Spiritual Counselor
E.Licensed Practical Nurse
F.Aide

O5020. Level of care in final 7 days

Did the patient receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final 7 days of life?

checked/> 0 - No checked/> 1 - Yes (Skip to Z0400, Signature(s) of Person(s) Completing the Record)

	Visits three day prior to death(A0270 minus 3)	Visits four day prior to death(A0270 minus 4)	Visits five day prior to death(A0270 minus 5)	Visits six day prior to death(A0270 minus 6)
A.Registered Nurse
B.Physician (or Nurse Practitioner or Physician Assistant)
C.Medical Social Worker
D.Chaplain or Spiritual Counselor
E.Licensed Practical Nurse
F.Aide

Record Administration

Z0400. Signature(s) of Person(s) Completing the Record

I certify that the accompanying information accurately reflects patient assessment information for this patient and that I collected or coordinated collection of this information on the dates specified. To the best of my knowledge, this information was collected in accordance with applicable Medicare and Medicaid requirements. I understand that reporting this information is used as a basis for payment from federal funds. I further understand that failure to report such information may lead to a 2 percent age point reduction in the Fiscal Year payment determination. I also certify that I am authorized to submit this information by this provider on its behalf.

Signature	Title	Sections	Date Section Completed
			Date Format: mm/dd/yyyy

Z0500.Signature of Person Verifying Record Completion

A. Signature:

B.Date

Date Format: mm/dd/yyyy