Patient Location

Date of Face to Face

Medical Condition
The encounter with the patient was in whole, or in part, for the following medical condition, which is the primary reason for the home healthcare is wounds to bilateral lower extremities.

Medical Necessity
I certify, that based on my findings, the following services are medically necessary home health services: Intermittent Nursing.

Clinical Findings
My clinical findings support the need for the above services because: Disease management/education/monitoring for potential exacerbation, (My clinical findings support the need for the above services because: Functional Decline w/ decreased mobility, generalized weakness, decreased strength or unsteady gait.)

Homebound Status
Further, I certify that my clinical findings support that this patient is homebound (i.e. absences from home require considerable and taxing effort, and are infrequent or of short duration when for other reasons) BECAUSE: Patient requires 24 hour supervision and is unable to leave facility unassissted for outpatient services which would require considerable and taxing effort.

VISIT ORDERS:

TODAYS ORDERS:

MEDICATION ORDERS:
NO medication changes today. Continue current medications.

LAB ORDERS:
NO lab orders today.

DIAGNOSTIC ORDERS:
NO diagnostic orders today.

OTHER ORDERS:
FTF for HHSN to assess and treat wounds to bilateral lower extremities.