Free 48731.FH11 - Indiana

MEDICAID HOSPICE PLAN OF CARE
State Form 48731 (R3 / 2-09) / OMPP 0011

The information contained on this completed form is CONFIDENTIAL according to 405 IAC 1-16, 5-2-10.1, 5-2-10.2, 5-5-1, and 5-34.

Reset Form
Primary hospice diagnosis (ICD-#): Recipient's Medicaid number

A. RECIPIENT INFORMATION
Name of recipient (last, first, middle initial) Recipient's Social Security number

B. HOSPICE PROVIDER INFORMATION
Name of hospice provider Hospice provider number

C. ASSESSMENT: Complete the following using the problem severity code listed at the bottom of the chart. ASSESSMENT Altered Physical Comfort Altered Respiratory Status Altered Cardiovascular Status Altered Nutritional Status Altered Skin Integrity Altered Mobility Status ACTIVITIES OF DAILY LIVING Eating / Feeding Grooming / Hygiene Bathing Dressing PROBLEM SEVERITY CODE PROBLEM SEVERITY CODE ASSESSMENT Alltered Urinary Elimination Altered Bowel Elimination Altered Sleep Pattern Altered Grief/Spiritual (patient) Altered Grief/Spiritual (family) Altered Oral Mucosa ACTIVITIES OF DAILY LIVING Toileting Continence Transferring Mobility PROBLEM SEVERITY CODE 0 = None: no problem present 1 = Problem: controlled at time of assessment 2 = Mild: function could be improved. 3 = Moderate: able to function with support 4 = Marked: able to function only with daily intervention 5 = Severe: incapacitated by the problem PROBLEM SEVERITY CODE PROBLEM SEVERITY CODE

D. SERVICES: Document the proposed services for this benefit period (include frequency and expected outcome). Services Required Skilled Nursing Frequency Expected Outlook

(Continued on the reverse side)

E. SERVICES (continued) Services Required Home Health

Frequency

Expected Outlook

Therapy

DME

Pharmacy

Spiritual

Other enhanced services

F. SIGNATURES: Date and sign the following. Signatures must represent the Medical Director as well as two signatures from any of the other disciplines listed above.
Signature Signature Signature Title Title Title Date (month, day, year) Date (month, day, year) Date (month, day, year)