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Run: Home Health Plan of Care (485) Development and Review

This Home Health Plan of Care (485) Development and Review template helps you document diagnoses, homebound status, ordered visits, medications, treatments, ...

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Patient and Certification Information

Patient full name (required)

Date of birth (required)

Medical record number

Certification start date (required)

Certification end date (required)

Plan of care type (required)

Primary payer

Clinical Summary and Diagnoses

Primary diagnosis (required)

Secondary diagnoses

Clinical summary (required)

Brief summary of the patient's current condition, homebound status, and skilled need. Collect only information needed for care planning.

Homebound status (required)

Functional limitations

Ordered Disciplines and Visit Frequency

Ordered disciplines (required)

Visit frequency by discipline (required)

Therapy goals summary

Medications and Treatments

Medication reconciliation completed (required)

Ordered medications

Ordered treatments and procedures

Include wound care, catheter care, injections, monitoring parameters, and other ordered treatments as applicable.

Monitoring parameters

Document any required monitoring, thresholds for escalation, and frequency of review.

Measurable Goals and Progress Review

Short-term goals (required)

Long-term goals

Goal progress since last review (required)

Barriers to progress

Physician Review, Consent, and Submission

Patient or representative acknowledgment (required)

I acknowledge that this plan of care was reviewed with me or my representative, as applicable.

Yes No N/A

Consent to share plan of care with treating providers (required)

I consent to the minimum necessary sharing of this plan of care for treatment, payment, and healthcare operations as permitted by law.

Yes No N/A

Physician name (required)

Physician review date (required)

Physician signature (required)

Submission notes

Add any clarification needed for the reviewer. Do not include unnecessary PII.

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Email (required)

Your name (optional)

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