25354 Evergreen Rd.
Southfield MI, 48075
Tel. 800.430.0309/Fax:248.569.2148
Continuing Plan of Care
Patient Name(Last, First, Middle Initial)
Address for Care
Telephone No.
To Agency:
Focus Care Home Health
25354 Southfield Rd.
Southfield MI, 48075
Tel. 800-430-0309 Fax:248-569-2148
From
Patient's Address(if not same as above)
Telephone No.
Complete Date of birth
Sex
Male
Female
Referral Date
Reported By
Date of First visit
Reported To
Marital Status
S
M
W
D
Responsive Relative or Friend
Relationship
Telephone No.
Hospital Case No
Room No.
Admission Date
Discharge Date
Hospital for drugs & supplies
Medicare No.
Medicaid No.
PPOM No.
Name of Subscriber
Other Insurance
Policy No.
REPORTED BY PHYSICIAN
Diagnosis (List Primary First & Date of Onset)
Surgery Performed & Dates
Complications
Prognosis
Good
Fair
Guarded
Poor
Patient Informed of diagnosis
Yes
No
Family Informed of Diagnosis
Yes
No
Rehabilitation
Brief Medical History
Visit to M.D.
Office
Clinic
Date of Visit
MEDICAL ORDERS AND PLAN OF TREATMENT
Diet
Activity
Medications Please: Check Meds. / Orders @ Home
Services Requested
Skilled Nursing
Social Worker
Physical Therapist
Speech Therapist
Occupational Therapist
HHAide
Durable Equipment Needed
Lab Draws
Ordered From (Company & Tel.)
I certify that the above patient is under my care, requires that the above Home Health Services, and is confined to his/her home. These professional services are to be provided in an intermittent basis and I will review the established plan atleast every two months. These servicves are related to the diagnosis stated above and conditions for which he/ she received treatment while recently hospitalized.
Physician Name
Addrerss
UPIN No.
Telephone No.
License No.
Date