careconnection face to face progress note and certification · 2016. 11. 29. · please include the...
TRANSCRIPT
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CareConnection Face to Face Progress Note and Certification
..hh
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STEP 1:Go into patient’s Progress Note.
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STEP 2:Add a Physician Progress Note.
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Add as a Physician Progress Note. If you want to save this
as a “Favorite,” click on “Precompleted” tab.
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Shows Physician Progress Note.
Click “Ok”
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Click in Free Text area or click on “Other” which will open the free text
box.
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STEP 3:Type in “..hh”, then
double click on the “..hh” in the drop down menu.
Screen will initially pop up as blank. Then follow
Step 3.
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Once the ..hh is double clicked, this Addendum will automatically appear.
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STEP 4:To complete each blank,
hold Control & F3 to scroll to each area. Be sure to complete ALL areas.
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***NOTE:Please title your
Progress Note as: Face to Face Progress Note or Home Health
Progress Note.
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Be sure to sign and date note.
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For Standardization of F2F Progress Note
Please include the ..hh Home Health F2F Progress Note and Certification at the bottom of your Physician Note.
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Face to Face Progress Note/Home Health Progress Note
Physician Signature and Date
Signature Line Electronically Signed On 08/07/2016 09:26 AM
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Example 1: Completed Face to Face Progress Note/Home Health Progress Note
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Example 2: Completed Face to Face Progress Note/Home Health Progress Note Patient: Jane Doe
Associated Diagnoses: CAD, Stroke, Respiratory Failure
Face to Face Encounter: Date & Time 08/07/16 09:13:00
Clinical Reason for Home Care: Recent admission for CAD, stroke and respiratory failure, requiring new supplemental oxygen; recent tongue cancer diagnosis with dysphagia, and new PEG placed as well.
Homebound Status: (Narrative documentation)
(1) This patient is homebound because an illness or injury renders him/her normally unable to leave home except with the assistance of another individual and leaving the home requires a considerable and taxing effort: Pt presents with heart disease of such severity that they must avoid all stress and physical activity has difficulty breathing while ambulating and is on oxygen.
(2) This patient is homebound because an illness or injury renders him/her normally unable to leave home except with the assistance or the aid of a supporting device and leaving the home requires a considerable and taxing effort: Pt presents with paralysis from stroke and is confined to a wheelchair and requires assistance of another person to transfer.
Home Care Interventions/Plan:
Skilled Nursing: needed for assessment and teaching on enteral feedings, complications of G-tube and complexity of diagnosis and New Medication.
Physical Therapy: needed for Gait Training, Strengthening, and Balance Exercises.
Occupational Therapy: needed for Compensatory strategies for cognitive impairments and Environmental modifications.
Certification statement signed by the physician: I certify/recertify that this patient is confined to his/her home (and meets homebound criteria) and needs intermittent skilled nursing care, physical therapy and/or speech therapy or continues to need occupational therapy. The patient is under my care, and a plan of care has been initiated and will periodically be reviewed by a physician. I (or an acute/post physician or collaborating NPP) had a Face-to-Face encounter with this patient on the above date, during which the primary reason for home health services was addressed. I have a clinical note (supporting documentation) documenting my encounter with the patient in the patient’s medical record to support certification and eligibility for home care, and will make it available to Advocate Home Health Services upon request.”
Following the Patient in the Community /Outpatient Managing Physician:
a. I am the certifying physician and will follow the patient in the community.
b. “I am the certifying physician, but Dr. (name and credentials) will follow the patient in the community
Physician Signature and Date
Signature Line Electronically Signed On 08/07/2016 09:26 AM __________________________________________________