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 times/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

Which careplan database to use?

checked>Use ONLY SmartDX database checked>Use ONLY Agency database checked>Use BOTH Agency and SmartDX databases checked>Don't use any database

Filter by 'Compliance with Medical Instructions' (M1033)?

checked--->> Yes

Filter by 'Type/Source of Assistance' (M2102)?

checked--->> Yes

Comments

Patient's Own Words:

Strengths

Goals

Care Preference

Risk Factor

Interventions

Add Vital