CM Initial Assessment

Assessment

Skilled Services Provided 

All skilled services that the resident will receive

Exclusions 

Any exclusions from the payer

Prior Level Of Function 

Resident's prior level of function before the skilled stay

Home Situation 

Resident's living situation

Caregiver Support 

Any support the resident receives from a caregiver

Any Community Supports Used 

Any support the resident receives from the community

List Any Prior DME 

Any durable medical equipment the resident used prior to the skilled stay

Medical Supplies 

Medical supplies for the resident

Current Level Of Function 

Resident's current level of function

Physical Therapy 

Resident's physical therapy requirements

Occupational Therapy 

Resident's occupational therapy requirements

Speech Therapy 

Resident's speech therapy requirements

Wounds 

Wound treatment requirements

Medication 

Medication requirements

Specialty DME Needs 

Specialty durable medical equipment requirements

LT Therapy Goal 

Long term therapy goal

DPOA 

Does the resident have a Durable Power of Attorney

DPOA (Notes) 

Durable Power of Attorney notes

Advanced Directives 

Does the resident have an advanced directive

Advanced Directives (Notes) 

Advanced directive notes

POLST 

Does the resident have Physician Orders for Life-Sustaining Treatment

POLST Notes 

Physician Orders for Life-Sustaining Treatment notes

Number of Stairs in prior living environment 

Stairs in the resident's prior living environment

POA/Responsible Party 

Does the resident have a responsible party for the power of attorney

POA/Responsible Party Name 

Name of responsible party

POA/Responsible Party Phone

Phone number of the responsible party

Sent? 

Has the initial paperwork been sent to the payer

Date 

Date intial paperwork was sent to payer

Notes 

Notate any additional information