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progress

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M2200 - Therapy Need: If Medicare, how many total therapy visits are indicated for this episode (total of OT, PT and ST visits)?

#AssForm.M0826_Ther_Need#0" maxlength="3">

total therapy visits

checked> NA - Not Applicable

Braden Scale complete Braden Scale incomplete

waiting for evaluation?

checked> Yes

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

M2250 Plan of Care Synopsis: Does the physician-ordered plan of care include the following?

a. Specific parameters for vital signs, etc.

checked> 0 - No checked> 1 - Yes checked> NA - Not applicable

e. Pain intervention(s)

checked> 0 - No checked> 1 - Yes checked> NA - Not applicable

b. Diabetic foot care including education

checked> 0 - No checked> 1 - Yes checked> NA - Not applicable

Fall Assessment complete Fall Assessment incomplete

f. Pressue Ulcer prevention

checked> 0 - No checked> 1 - Yes checked> NA - Not applicable

Pain assessment complete No Pain Pain assessment incomplete

c. Falls prevention intervention(s)

checked> 0 - No checked> 1 - Yes checked> NA - Not applicable

g. Moist wound pressure ulcer treatment

checked> 0 - No checked> 1 - Yes checked> NA - Not applicable

d. Depression intervention(s)

checked> 0 - No 1 - Yes checked> NA - Not applicable

M0090 Date Completed

Date Format: mm/dd/yyyy

Comments

Patient's Own Words:

Strengths

Goals

Care Preference

Risk Factor

Interventions

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