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HOME HEALTH REPORT State Form 51449 (7-03) Indiana State Department of Health 410 IAC 17-10-1 (o)

I. IDENTIFICATION OF THE ORGANIZATION Name of Agency Street Address City County II. SOURCE OF ADMISSION REFERRAL SOURCE FROM Self or Family Physician Referral Health Department Hospital (Inpatient or outpatient) Nursing Facility Other /Unknown Total Admissions and Carry Over NUMBER OF PATIENTS State Person Completing Form

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III. DEMOGRAPHIC CHARACTERISTICS OF PATIENTS AGE GROUPS Under 1 Year Old 1 to 4 Years 5 to 14 Years 15 to 24 Years 25 to 44 Years 45 to 64 Years 65 to 74 Years 75 to 84 Years 85 Years and Older Total Patients By Gender MALES FEMALES

IV. DIAGNOSTIC CHARACTERISTICS OF PATIENTS PRIMARY DIAGNOSIS Infections, Parasitic (001-041, 045-139) Acquired Immunodeficiency Syndrome (042-044) Neoplasms (140-239) Endocrine, Nutritional , Metabolic (240-279) Blood, Lymph, Spleen (280-289) Emotional, Mental (290-319) Nervous System, Sense Organs (320-389) Circulatory system (390-459) Respiratory system (460-519) Digestive System (520-579) Genitourinary System (580-629) Pregnancy, Puerperium (630-679) Skin, Subcutaneous Tissue ( 680-709) Musculoskeletal Connective (710-739) Congenital Anomalies (740-759) Perinatal (760-779) Symptoms, Ill Defined Conditions (780-799) Injuries, Poisoning, Violence (800-999) NUMBER OF PATIENTS

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Other Medical with no ICD-9-CM Code All Patients

V. GEOGRAPHIC DISTRIBUTION AND IDENTIFICATION OF NUMBER OF PATIENTS AND VISITS BY COUNTY NAME OF COUNTY NUMBER OF PATIENTS NUMBER OF MEDICAL VISITS NUMBER OF HOURS (OPTIONAL)

TOTAL VI. DISCHARGE DESTINATION DISCHARGE DESTINATION To Hospital To Nursing Facility To Self or Family To Hospice To Other Agency for Continuing Care Patient Died Other (Refused Care, Moved, etc.) Total Discharges NUMBER OF DISCHARGES

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VII.

ESTIMATE OF FUNCTIONAL REHABILITATION PROGNOSIS PERCENT ESTIMATE OF POTENTIAL

LEVEL OF INDEPENDENCE Percent of Patient with Good prognosis for improvement Percent of Patients with minimum improvements expected

VIII OVERALL CHANGE IN CARE NEEDS OF ALL PATIENTS EXPECTED POTENTIAL FOR RECOVERY UPON ADMISSION Good Recovery Potential Poor Recovery Potential Unknown or No Change Expected in Recovery VIII. SOURCE OF PAYMENT THIRD PARTY PAYER Medicare Medicaid Medicaid Waiver CHOICE Other Government (Local, state, federal) Private Health Insurance Health Maintenance Organizations Community Funds (i.e. contributions) Self Pay / Family Payment Uncompensated Other Payment Source Total from all Payers X. COMMENTS NUMBER OF PATIENTS NUMBER OF PATIENTS

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