Home Health Plan of Care/Physician Orders (485-Style)

Document Status: [Draft / Pending Signature / Signed]

Patient: [Full legal name] | [DOB: MM/DD/YYYY] | [MRN/Agency ID] | [Address of service] | [Primary phone] | [Emergency contact name, relationship, phone]

Payer Identifiers: [Medicare Beneficiary Identifier (MBI)] | [Payer/member ID] (If not applicable, enter N/A.)

Home Health Agency: [Agency name] | [NPI] | [Phone] | [Fax] | [After-hours number] | [Clinical manager name and contact]

Certifying Practitioner: [Name, credentials] | [NPI] | [Practice name] | [Phone] | [Fax]

Episode Dates: [Start of care date: MM/DD/YYYY] | [Certification period: MM/DD/YYYY to MM/DD/YYYY]

Referral Source: [Facility/clinic] | [Discharge date: MM/DD/YYYY] | [Primary reason for home health]

Eligibility and Certification Support

Homebound Rationale: [Patient-specific rationale describing why leaving home requires considerable and taxing effort, including: required assistive devices, level of human assistance needed, exertion-triggered symptoms, safety risks, environmental barriers] (Use concrete functional details. Avoid vague or generic language.)

Skilled Need Summary: [Qualifying skilled discipline(s) with 1–2 sentences linking skilled need to diagnoses and objective deficits or risks]

Face-to-Face Encounter: [Encounter date: MM/DD/YYYY] | [Performer name, credentials] | [Relationship of encounter to primary reason for home health] (If pending: "Pending—to be obtained" with plan and responsible party.)

Diagnoses and Clinical Summary

Primary Diagnosis: [ICD-10 code] – [Diagnosis description most related to current skilled services] (If uncertain: "Diagnosis per referral—pending confirmation.")

Secondary Diagnoses:

• [ICD-10 code] – [Comorbidity description]
• [ICD-10 code] – [Comorbidity description]
• (Add lines as needed. Do not infer diagnoses.)

Clinical Summary: [Precipitating event, current clinical status, key risks, care priorities, and any high-risk therapies/devices such as oxygen, wound vac, central line, enteral feeding] (Do not introduce diagnoses that are not documented.)

Patient Status and Limitations

Cognitive/Psychosocial Status: [Orientation status, cognitive impairments affecting learning/safety, mood/behavioral concerns, caregiver involvement if cognition limits self-management] (If not applicable, state N/A with brief reasoning.)

Prognosis: [Condition-appropriate prognosis statement with clinical reasoning]

Rehabilitation Potential: [Good / Fair / Guarded / Poor] (If therapy not ordered, document rationale.)

Functional Limitations: [Mobility, ADLs/IADLs, transfers, endurance, continence; required assistive devices; level of assistance needed] (If not applicable, state N/A with brief reasoning.)

Activity Orders: [Weight-bearing status, lifting restrictions, ROM precautions, fall precautions] (Use "as tolerated" only when clinically appropriate and consistent with medical/surgical instructions.)

Nutritional Requirements: [Diet type, fluid restrictions, supplements, tube feeding regimen if applicable]

Safety Measures: [Individualized measures for: falls prevention, infection control, line/tube safety, pressure injury prevention, medication safety, oxygen fire safety if applicable]

Readmission Risk and Mitigation: [Risk description including clinical and social drivers] | [Interventions: symptom monitoring parameters, escalation criteria, medication reconciliation, caregiver training, follow-up appointments]

Advance Directives: [Presence/absence of AD/DNR/POLST] | [Document location] | [Parties aware of directives]

Ordered Services

(Include only disciplines ordered. Do not infer frequency or duration; use "Pending practitioner order" if not provided.)

Discipline	Frequency	Duration	Primary Purpose	PRN Parameters
[SN / PT / OT / SLP / MSW / HHA]	[e.g., 2 visits/week × 2 weeks, then 1 visit/week × 6 weeks; or 1–3 visits/week × 4 weeks]	[Total weeks in certification period]	[Primary purpose tied to skilled need]	[Trigger signs/symptoms AND numeric visit limit; or N/A]

Goals and Measurable Outcomes

(Include 2–5 global patient-centered goals plus problem-specific goals for each active problem. Each goal must include baseline, measurable target, timeframe, and responsible discipline.)

Global Patient-Centered Goals

• Goal: [Patient-centered goal] | Baseline: [Current status] | Target: [Measurable outcome] | Timeframe: [Date or weeks] | Responsible: [Discipline(s)]

Problem-Specific Goals

[Problem/Domain Name]

• Goal: [Functional/clinical goal] | Baseline: [Objective baseline] | Target: [Measurable metric] | Timeframe: [Date or weeks] | Responsible: [Discipline(s)]

Skilled Orders by Discipline

(Include only disciplines ordered. Use action verbs and link interventions to goals. Specify what + how + frequency + duration + special instructions.)

Skilled Nursing Orders

(Include only if SN ordered.)

• Assessment/Monitoring: [Parameters to assess, frequency, documentation requirements]
• Medication Management: [Reconciliation, administration support, teaching (purpose/dose/timing/side effects), adherence strategies, high-risk medication precautions]
• Disease-Specific Teaching: [Warning signs, self-management steps, when to call, when to seek emergency care]
• Wound/Ostomy Care: [If applicable; cross-reference Treatment Orders section]
• Lab Draws: [Test, frequency, collection instructions, results destination, who acts on abnormals]
• Care Coordination: [Provider updates, equipment coordination, appointment scheduling]

Physical Therapy Orders

(Include only if PT ordered.)

• Evaluation: [Scope and objective measures for baseline]
• Interventions: [Therapeutic exercise, gait/balance training; type, intensity, frequency, safety precautions]
• Equipment/Safety: [Assistive device training, home safety modifications]
• Home Program: [Exercises, dosage, frequency, progression criteria]

Occupational Therapy Orders

(Include only if OT ordered.)

• Evaluation: [ADLs/IADLs, cognition impacting self-care, environmental barriers]
• Interventions: [ADL retraining, energy conservation strategies]
• Equipment/Safety: [Adaptive equipment training, home safety recommendations]
• Caregiver Training: [Safe assistance techniques]

Speech-Language Pathology Orders

(Include only if SLP ordered.)

• Evaluation: [Cognitive-communication and/or language assessment scope]
• Dysphagia Management: [Assessment, diet texture recommendations, aspiration precautions]
• Communication: [Strategies and caregiver training]
• Home Program: [Practice activities and outcome measures]

Medical Social Work Orders

(Include only if MSW ordered.)

• Assessment: [Psychosocial factors, SDOH, caregiver burden]
• Resources: [Community resources, benefits assistance]
• Care Planning: [Advance directive facilitation, discharge planning support]

Home Health Aide Orders

(Include only if HHA ordered.)

• Personal Care: [Tasks, frequency, duration]
• Bathing/Skin Care: [Schedule, skin observation and reporting requirements]
• Safety: [Reinforcement activities aligned to patient risks and activity orders]

Treatment Orders

(Include subsections only when applicable. Use discrete order sentences: what + how + frequency + duration + special instructions.)

Wound Care

(Include only if wounds present.)

• Wound: [Location/type/stage] | Measurements: [Frequency] | Cleansing: [Solution, method] | Dressing: [Type, change frequency] | Offloading: [Instructions] | Escalation: [Infection signs, notification criteria]

Device/Line Care

(Include only if devices/lines present.)

• Urinary Catheter: [Type] | [Care protocol] | [Change schedule] | [Infection signs and escalation]
• Central Line/PICC: [Dressing change protocol] | [Flush protocol] | [Cap change schedule] | [Infection/occlusion escalation]
• Enteral Feeding: [Formula] | [Rate/schedule] | [Flushes] | [Aspiration precautions] | [Tube site care]
• Oxygen: [LPM] | [Delivery device] | [Target SpO2] | [Titration parameters if applicable] | [Fire safety instructions]

Labs/Diagnostics

(Include only if ordered.)

• [Test name] | [Frequency] | [Collection instructions] | [Results destination] | [Responsible clinician and timeframe for acting on abnormals]

DME and Supplies

(Include only if ordered.)

• DME: [Equipment needed for safety/function with justification]
• Supplies: [Medical supplies required for ordered treatments]

Care Coordination and Notification Parameters

Practitioner Notification Thresholds:

• Call practitioner for: SBP <[value] or >[value]; DBP <[value] or >[value]; HR <[value] or >[value]; Temp >[value]°F; SpO2 <[value]% on ordered O2; BG <[value] or >[value] mg/dL
• Call for: weight change >[value] lb in [timeframe]; new/worsening dyspnea; chest pain; acute neurologic changes; falls; uncontrolled pain; wound infection signs; device malfunction; medication adverse effects
• Hold therapy and notify if: [Specific clinical conditions or parameters]

Medication Discrepancy Process: [Process for resolving discrepancies found in home: who to contact, timeframe for resolution and documentation]

Communication Plan: [Providers receiving plan updates] | [How/when changes communicated to patient/caregiver] | [Primary contact for urgent issues]

Patient and Caregiver Education

Education Topics: [Diagnosis-specific self-management, medication teaching (purpose/dose/timing/side effects/red flags), equipment use, infection prevention, fall prevention, emergency plan] (Individualize to patient risks and learning needs.)

Competency Validation: [Teach-back and return demonstration requirements, competency criteria, barriers identified (cognitive, language, health literacy), mitigation strategies including interpreter needs]

Discharge Planning

Anticipated Disposition: [Self-care / Outpatient therapy / Clinic follow-up / Other]

Discharge Criteria: [Objective goal attainment criteria and patient/caregiver competency criteria for safe discharge]

Post-Discharge Plan: [Follow-up appointments, medication refills, community resources, handoff plan to PCP/specialists]

Certification and Signature

Certification Attestation: [Statement that practitioner has reviewed this Plan of Care and certifies the patient is homebound (when required), requires intermittent skilled nursing care and/or therapy services, and that services are under their care for the certification period MM/DD/YYYY to MM/DD/YYYY]

Practitioner Signature: ____________________________ | Printed Name/Credentials: ____________________________ | Date: ____/____/________

(Plan of care must be signed and dated before claim submission for each billing period.)