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PREVISIT
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Telephone
call prior to visit
• Telephone availability
• Setting appointment time
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M0770
M0770,
M0400, M0410, M0560
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VISIT
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Basic
demographic information
• Name, address, age, gender, pay source,
etc.
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M0010-M0160
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Entrance
to home
• Stairs or structural
barriers
• Patient's ambulatory
status
• Patient remembered
telephone call & appointment
• Interior of home (as move from one room
to another)
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M0310
M0700
M0560, M0570
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Interior
of home (as move from one room to another)
• Lighting
• Floor coverings
• Room temperature
• Electrical outlets
• Doorways or other structural barriers
• Walls, windows, window coverings
• Odors (gas from stove, urine, feces)
also M0520-M0540
• Kitchen (where you might wash your hands)
- water availability, status of sink
- appliances available
- food out on counter tops or table
- evidence of insects or rodents
- medications present in bottles or scattered
• Bathroom (where you might wash your
hands or what you ask to see to set up aide care plan)
- water availability, status of sink
- bathtub or shower
- assistive equipment (grab bars, shower
chair)
- toilet
- soiled clothes with urine or fecal odor
- medications present in bottles or scattered
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M0310, M0320, M0330, M0750
also M0520-M0540
also
M0780-M0800
M0670, M0680
also M0520-M0540
also M0780-M0800
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History
of present condition and symptoms
• Hospitalization and reasons
• Onset of current illness
• Other comorbidities (severity and management)
• Presence of high risk factors
• Life expectancy
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M0175-M0190
M0200-M0220
M0250, M0500, M0510
M0290
M0280
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Family/caregiver
assistance
• Living situation
• Availability of family/caregiver assistance
• Other assistance needed and received
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M0300, M0340
M0350, M0360
M0360-M0380, M0820
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Medication
inventory
• Walk to where meds
are kept
• Assess knowledge
of medication schedule, dosage, etc.
• Assess ability to administer prescribed
medications
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M0690-M0700
M0410, M0560
M0780-M0800
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Physical
assessment
• Vital signs
- orthostatic BP
- comprehension of instructions
• Weight
- comprehension of instructions
- ability to stand, step on scale
• Head
- vision
- hearing
-speech
• Skin condition
• Musculoskeletal and neurological
- joint function, grasp, pain, etc.
- neurologic
• Cardiorespiratory
- dyspnea
- lung sounds; check ability to dress
upper body
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circulation in lower extremities; check ability to dress lower body
• GI/GU
- urinary status
- bowel status
• Nutritional status
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M0690
M0400, M0560-M0570
M0400,
M0560-M0570
M0690-M0700
M0390
M0400
M0410
M0440-M0488
M0640-M0660, M0780-M0820
also M0410-M0430,
M0560
M0490
M0650
M0660
M0520-M0530
M0540-M0550
M0710-M0720, M0760
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Emotional/behavioral
status assessment
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M0560-M0620
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ADLs/IADLs
• Review any information not gathered
already in sufficient detail
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M0670-M0680, M0730-M0760
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POSTVISIT
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Data
review (in preparation for care planning)
• Primary diagnosis and comorbidities
• Severity index
• Prognosis and rehab prognosis
• Need for psychiatric nursing services
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M0230, M0240
M0240
M0260,
M0270
M0630
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