Current Pat. Status: Outpatient

Primary Eligibility: SHARING AGREEMENT

Order Information

To Service: HOME HEALTH (SKILLED)

From Service: COMMUNITY HEALTH/HOME HEALTH

Requesting Provider: MITCHELL,AMY L

Service is to be rendered on an OUTPATIENT basis

Place: Consultant\'s choice

Urgency: Routine

Orderable Item: HOME HEALTH (SKILLED)

Consult: Consult Request

Reason For Request:

Diagnosis for Home Health: COPD, CHF, Venous Stasis Ulcers

Active Outpatient Medications (including Supplies):

Active Outpatient Medications Status

=========================================================================

1\) DEXAMETHASONE OP OINT 0.05%,3.5GM APPLY THIN RIBBON ACTIVE

TO AFFECTED EYE(S) FOUR TIMES A DAY \*\*\*TEST

ONLY\*\*\*\*\*

2\) TABLET CUTTER USE AS DIRECTED MISCELLANEOUSLY NONE ACTIVE

\*\*\*TEST ONLY\*\*\*\*\*

3\) TIMOLOL MALEATE 0.25% OPH SOLN INSTILL 1 DROP IN ACTIVE

AFFECTED EYE(S) FOUR TIMES A DAY

FUTURE APPOINTMENTS:

NOV 14, 2002@09:00 Clinic: GPA/RAO (F/U)

Level of Care:

Needs Assistance

Total Care/Dependent

Mental Status:

Alert & Oriented

Other:

Wound Care:

Wound description: chronic ulcers, large, deep

Wound care orders: cleanse with NS, apply Panafil, QD

Home Health Services Requested:

RN: Skilled assessment, Medication teaching/compliance, Wound

care/management, Other: PICC line care and IV therapy

Rehab Services:

P.T. Specify: ROM exercises, ambulation

O.T. Specify: eval ADL\'s

S.T. Specify: swallowing eval

Aide/Personal Care Specify: 3x/week personal care assistance

Lab Orders Specify: protime/INR qweek

Infusion Services:

Drug/Dose/Route/Frequency/Duration

Drug #1: Vancomycin 1 GM. QD IV for 6 weeks

Drug #2: Ceftazadine 2 Gm. QD IV for 6 weeks

Venous Access: PICC

Allergies:

METHOTREXATE, PENICILLIN-SENSITIVE, IODINE, RADIOLOGICAL/CONTRAST MEDIA

IODINE \<RADIOLOGICAL/CONTRAST MEDIA\>

Bowel & Bladder Care Specify: 3x/week per written instructions

Other: MSW eval. for community resources

Home Health Agency Preference?

No

Unknown

Yes Specify: IVNA Home Health

Date to Start Home Health:

Inpatient:

Admission Date:

Discharge Date (anticipated): Jun 14,2002

Start Date: Jun 15,2002

Outpatient:

Start Date: Jun 15,2002

Comments: Patient is receiptive to home health services. Lives with

family

who are supportive and willing to learn care. Patient has been

taught wound care and IV therpay but needs further education.

Inter-facility Information

This is not an inter-facility consult request.

Status: COMPLETE

Last Action: COMPLETE/UPDATE

Facility

Activity Date/Time/Zone Responsible Person Entered By

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

CPRS RELEASED ORDER 06/14/02 18:32 MITCHELL,AMY L MITCHELL,AMY L

PRINTED TO 06/14/02 18:33

HOMEHEALTH\$PRT

COMPLETE/UPDATE 06/15/02 10:25 MITCHELL,AMY L MITCHELL,AMY L

Note# 2877670

Note: TIME ZONE is local if not indicated

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

\<\< Interdisciplinary Note \>\>

TITLE: HOME CARE SERVICES CONSULT (TL) CHNC INITIAL (S)

LOCATION: COMMUNITY HEALTH/HOME VISIT DATE: JUN 15, 2002@10:23

DATE OF NOTE: JUN 15, 2002@10:23 ENTRY DATE: JUN 15, 2002@10:23:28

AUTHOR: MITCHELL,AMY L EXP COSIGNER:

URGENCY: STATUS: COMPLETED

Consult received for home care services to begin on (date): Jun 15,2002

Previous referral:

Community Health/Home Health has no record of previous referrals for
home

care.

Patient followed in the past by agency:

IVNA Home Health, 355-7100

Other:

Payment Source:

Payment source unknown at this time/to be determined.

Patient may not have payment coverage and may need VA payment/approval

through Fee Basis.

Patient has payment coverage for home care (specify):

Medicare

Other:

Consult/referral will be forwarded to team for completion of Home Care

Services Interdisciplinary Notes and for followup to:

IVNA Home Health Coordinator

Comments: Home Care consult/referral received from

4C/Medicine Team 3 for patient with COPD;CHF;Venous Stasis

Ulcers,

requesting home RN, P.T., O.T., Aide, MSW IV therapy

services.

/es/ AMY L MITCHELL

RN, Comm Health Nurse Coordinator

Signed: 06/15/2002 10:25

\<\< Interdisciplinary Note - Cont. \>\>

TITLE: HOME CARE SERVICES CONSULT (TM) CM

DATE OF NOTE: JUN 15, 2002@10:25 STATUS: COMPLETED

Additional home care services needed: teaching re: disease process and

management

Agency preference, if not specified in consult:

\[X\] No

\[X\] Yes: IVNA Home Health

Teaching completed (specify): Initial teaching re: IV therapy and PICC

line care.

Patient/significant other are agreeable with referral to home care: yes

/es/ AMY L MITCHELL

RN, Comm Health Nurse Coordinator

Signed: 06/15/2002 10:27

\<\< Interdisciplinary Note - Cont. \>\>

TITLE: HOME CARE SERVICES CONSULT (TM) SOCIAL WORK (S)

DATE OF NOTE: JUN 15, 2002@10:27 STATUS: COMPLETED

Social work assessment/summary: Veteran lives with his wife and adult

son. He served in the Army

and is a veteran of WWII. His family is supportive and provide

transportation to his appts., as well as care in the home.

Payment for home health:

\[X\] Medicare, Part A Effective Date: 1/1/77

\[X\] Medicare, Part B Effective Date: 1/1/77

Medicare #: 000-00-3232A

Other Insurance (specify): BCBS

Rated Disabilities: None found.

Other Eligibilities: None found.

VA compensation/pension: \$400.00

Other income: \$300.00

/es/ AMY L MITCHELL

RN, Comm Health Nurse Coordinator

Signed: 06/15/2002 10:30

\<\< Interdisciplinary Note - Cont. \>\>

TITLE: HOME CARE SERVICES CONSULT (TM) DIETITIAN (S)

DATE OF NOTE: JUN 15, 2002@10:30 STATUS: COMPLETED

Diet Order: Prudent

Height: Height: Not found.

Weight: 140 lb \[63.6 kg\] (03/19/2001 09:28)

IBW/UBW: Ideal Body Weight: Not found./Usual Weight: Not found.

Pertinent Labs: chem 10 results WNL

Appetite: good most of the time

Nutritional Summary/Comments: Patient and wife are knowledgeable re:

Prudent diet but need

reinforcement teaching re: foods high in salt and sugar. Also,

weight reduction of 20# was recommended.

/es/ AMY L MITCHELL

RN, Comm Health Nurse Coordinator

Signed: 06/15/2002 10:32

\<\< Interdisciplinary Note - Cont. \>\>

TITLE: HOME CARE SERVICES CONSULT (TM) REHAB

DATE OF NOTE: JUN 15, 2002@10:34 STATUS: COMPLETED

THIS IS A BLANK TEMPLATE NOTE\...THE KT/PT/OT/ST CAN TYPE TEXT HERE AND
THEY CAN

ALSO CUT/PASTE OTHER TEMPLATES OR PROGRESS NOTES INTO THIS BLANK SPACE,
SO THEY

DON\'T HAVE TO DUPLICATE WORK THEY MAY HAVE ALREADY DONE.

/es/ AMY L MITCHELL

RN, Comm Health Nurse Coordinator

Signed: 06/15/2002 10:35

\<\< Interdisciplinary Note - Cont. \>\>

TITLE: HOME CARE SERVICES CONSULT (TM) CHNC FINAL (S)

DATE OF NOTE: JUN 15, 2002@10:36 STATUS: COMPLETED

Consult/referral faxed to agency/phone:

IVNA Home Health, 355-7100

Other:

Consult/referral received by agency, per phone confirmation

(date): Jun 14,2002

Patient provided with agency name/phone number on Jun 14,2002 by:

Community Health

Case Manager

Other:

Summary of home care services ordered:

Home Health Services:

RN: Skilled assessment, Medication teaching/compliance, Wound

care/management, Other:

Rehab Services:

P.T. Specify:

O.T. Specify:

S.T. Specify:

Aide/Personal Care Specify:

Lab Orders Specify:

Infusion Services:

Drug/Dose/Route/Frequency/Duration

Drug #1:

Drug #2:

Venous Access:

Allergies:

METHOTREXATE, PENICILLIN-SENSITIVE, IODINE, RADIOLOGICAL/CONTRAST MEDIA

IODINE \<RADIOLOGICAL/CONTRAST MEDIA\>

Bowel & Bladder Care Specify:

Other:

Patient/significant other are agreeable with referrral to home care.

Payment source for home care services:

Medicare

VAMC Fee Basis through Richmond

Other:

Initial home visit requested on (date): Jun 15,2002

Comments:

/es/ AMY L MITCHELL

RN, Comm Health Nurse Coordinator

Signed: 06/15/2002 10:39