.
5/9/16
5/10/16
5/11/16
5/12/16
5/13/16
5/14/16
5/15/16
5/16/16
5/17/16
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Place call log with documentation of conversation
Tell the client that they cannot receive home care if they refuse admission today
Immediately send an IPO to the physician requesting a physician ordered SOC date of 5/3/16 due to patient refusal
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5/5/16
5/6/16
5/8/16
5/9/16
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Codes must be reviewed to ensure they are pertinent and in correct order of importance to patient's care
Codes must be reviewed and additional codes must be requested if items appear to be missing
Codes and plan of care must be reviewed to ensure that the top 6 diagnosis codes are addressed in interventions and goals
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1 - Intravenous or infusion therapy (excludes TPN)
2 - Parenteral nutrition (TPN or lipids)
3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)
4 - None of the above
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1: Patient lives alone - Around the clock
2: Patient lives alone - Regular daytime
3: Patient lives alone - Regular nighttime
4: Patient lives alone - Occasional / short-term assistance
5: Patient lives alone - No assistance available
6: Patient lives with other person(s) in the home - Around the clock
7: Patient lives with other person(s) in the home - Regular daytime
8: Patient lives with other person(s) in the home - Regular nighttime
9: Patient lives with other person(s) in the home - Occasional / short-term assistance
10: Patient lives with other person(s) in the home - No assistance available
11: Patient lives in congregate situation (for example, assisted living, residential care home) - Around the clock
12: Patient lives in congregate situation (for example, assisted living, residential care home) - Regular daytime
13: Patient lives in congregate situation (for example, assisted living, residential care home) - Regular nighttime
14: Patient lives in congregate situation (for example, assisted living, residential care home) - Occasional / short-term assistance
15: Patient lives in congregate situation (for example, assisted living, residential care home) - No assistance available
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1 - Intravenous or infusion therapy (excludes TPN)
2 - Parenteral nutrition (TPN or lipids)
3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)
4 - None of the above
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0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.
1 - Minimal difficulty in expressing ideas and needs (may take extra time: makes occasional errors in word choice, grammar or speech intelligibility; needs minimal prompting or assistance).
2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.
3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener. Speech limited to single words or short phrases.
4 - Unable to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (for example, speech is nonsensical or unintelligible).
5 - Patient nonresponsive or unable to speak
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Ask the patient to rate their pain on a 0-10 scale. When they do not answer, chart that they denied pain.
Ask the staff to rate the patients pain
Complete the Pain AD form to assess for non-verbal signs of pain
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0 - Patient has no pain
1 - Patient has pain that does not interfere with activity or movement
2 - Less often than daily
3 - Daily, but not constantly
4 - All of the time
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Stage I
Stage II
Stage III
Stage IV
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0 - No
1 - Yes
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Orthopedic pin sites
Surgical incisions
Surgical excision of a pressure ulcer
Muscle flap repair to pressure ulcer
Central lines, implanted infusion devices
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Diabetic Ulcers
Chest Tubes
Edema
Burns
Cellulitis
Arterial Ulcers
Traumatic Wounds
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