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February 17 - 

February 1 -

Home Health (HH) Electronic Clinical Template

CMS has announced it will have one final scheduled call for its Home Health (HH) Electronic Clinical Template on April 28 at 1:30pm (EST). An updated version of the draft templates will be posted on the CMS HH Electronic Clinical Template website prior to the Open Door Forum.

The current draft of the electronic clinical template is posted below.

CMS has received numerous comments on the length of the template and how that makes it difficult for physicians /practitioners to complete the template. CMS reminds commenters about three things:

1. The use of a template is voluntary. Physicians/practitioners will not be required to use it.

2. Once a physician/practitioner completes the template, the resulting document is a progress note or office note that is part of the medical record for that patient. The note must contain all relevant information sufficient for patient care and sufficient for the physician/practitioner to bill for the appropriate level Evaluation and Management service.

3. The template is intended to be a “skip-template” where not all sections are relevant for all patients and therefore can be skipped.

Suggested Data Elements for an Electronic Clinical Template of a Physician Evaluation & Management Visit Note

DRAFTv4.4 03/09/15

Patient First Name:________________ Last Name:________________________ Date of Birth: / /

Date of in-person visit:

Is this visit related to the primary reason the patient requires home health services? □ Yes □ No


Chief Complaint: ___________________________________________________________________

History of Present Illness (HPI):

Location: _____________________

Quality: □ aching □ burning □ radiating □ other:_______________________________________________________________________

Severity: □ 1 □ 2 □ 3 □ 4 □ 5 □ 6 □ 7 □ 8 □ 9 □ 10

Duration: □ 1day □ 2days □ 3days □ other:__________________________________________________________________________

Timing: □ constant □ intermittent □ time of day?_______________________________________________________________________

Context: better/worse □ at work □ rest □ sleep □ other__________________________________________________________________

Moderating Factors: better/worse with □ heat □ ice □ other :__________________________________________________________

Associated Signs/Symptoms:________________________________________________________

Review of Systems (ROS):

Eyes: □ visual changes □ other_____________________________________________________________________________________

ENT: □ sore throat □ rhinitis □ other________________________________________________________________________________

CV: □ chest pain □ other__________________________________________________________________________________________

Res : □ SOB □ cough □ hemoptysis □ other____________________________________________________________________________

Gastro: □ nausea □ vomiting □ diarrhea □ abd pain □ other________________________________________________________________

GenitoUr: □ dysuria □ frequency □ urgency □other_____________________________________________________________________

Musc/Skel:^ back pain □ joint pain □ other_______________________________________________________________

Skin/Breast: □ rash □ itching □ other______________________________________________________________________________

Neurologi □ numbness □ dizziness □ other________________________________________________________________

Psych: □ anxiety □ depression □ other__________________________________________________________________

Endocrine: □ hypoglycemia □ thirsty □ other________________________________________________________________________

Hem/Lymph: □ anemia □ bleeding □ other_________________________________________________________________________

Allergy/Immune: □ deficiency □ other___________________________________________________________________________

Other: _________________________________________________________________________

Past, Family, and Social History:

Past: illnesses,_________________________________ operations:________________________________________________________


Social: ________________________________________________________________________________________________________


Constitutional: T=_________ P=____________ R=_____________ BP=_________ /_______ weight=_________________ O2Sat

General Appearance______________________________________________________________







Musc/Skel (include graded motor strength)


Extremitie s_______________________


Mobility/Functional assessment________


Homebound Status______________________________________________________________________

Medicare Definition of Confined to the Home (i.e., "homebound")

The patient is considered homebound if the following two criteria are met:

1) because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or assistance of another person in order leave their place of residence, or have a condition such that leaving his or her home is medically contraindicated.

2)   there must exist a normal inability to leave the home and if the patient does leave home, it requires a considerable and taxing effort.

If the patient does in fact leave the home, the patient may nevertheless be considered homebound if the absences from the home are infrequent or for periods of relatively short duration, or are attributable to the need to receive health care treatment.__________________________________

□   This patient meets the Medicare definition of "Confined to the Home."

□   This patient does not meet the Medicare definition of "Confined to the Home."

□     Patient is NOT homebound because she/he can leave home without assistance and it is not medically contraindicated for him/her to do so. (HHA Services are NOT covered by Medicare for this patient)

another individual and leaving the home requires a considerable and taxing effort. Patient needs the assistance of another individual to leave home because:

□   High fall risk due to gait instability and muscle weakness caused by :_____________________________________

□   Cognitive deficits impact judgment, impair ability to safely navigate and prevent decision making for safety.

□    Shortness of breath/distress after ambulating more than 10 feet results in high risk for falling

□   Other:___________________________________________________________________________

□     Patient IS homebound because an illness or injury renders him/ her normally unable to leave home except w/ aid of a supportive

device and leaving the home requires a considerable and taxing effort. Patient needs the assistance of a_ cane____ walker

___ wheelchair other (describe)_______________________ to leave home because:

□   Medical condition of_________________________________ results in instability, weakness, and/or pain w/ ambulation.

□   Recent lower extremity joint replacement results in instability, weakness, and/or pain with ambulation.

□   Patient is bedbound due to:_______________________________________________________________________

□   Other:_______________________________________________________________________________________

□     This patient IS homebound because an illness or injury renders him/ her normally unable to leave home as it is medically contraindicated and leaving the home requires a considerable and taxing effort. It is medically contraindicated for this patient to leave home because:

□   Patient is receiving care for a draining, infected wound

□   Patient is immunocompromised due to:_____________________________________________________________

□   Other:_______________________________________________________________________________________


□ This patient requires skilled nursing services: □ Teach/train the patient or caregiver to_____

□     Administer __ IV ___ IM __ SQ_____________________ (medication) that the patient/caregiver cannot safely


□   Provide skilled assessment and teaching of oral medication because:

□   Regimen is highly complex

□   Patient is confused

□   Patient has new medications ordered

□   Patient is experiencing side effects

□   Non-adherence to medication regimen is suspected

□   Other:____________________________________________________________________________________

□     Administer infusion therapy that the patient/caregiver cannot safely administer

□   Perform skilled__ wound care,__ catheter care, or_ ostomy care that the patient/caregiver cannot safely administer

□   Conduct a psychiatric nursing evaluation

□   Other:________________________________________________________________________________________

□ This patient requires the following: □ physical therapy, □ occupational therapy □ speech language pathology


□   To provide gait training, strengthening and/or balance exercises to restore the patient's ability to walk safely without pain.

□   To increase strength and endurance and restore ROM s/p__________________________________________ surgery.

□   To evaluate for assistive devices and/or environmental modifications needed to address ADL deficits to improve safety with transfers and ambulation

□   To teach the patient caregiver compensatory strategies for cognitive deficits

□   To teach the patient caregiver compensatory environmental modifications for safety.

□   To evaluate and treat Benign Paroxysmal Positional Vertigo (BPPV)

□   To evaluate and treat dysphagia

□   To evaluate and treat aphagia

□   To provide maintenance therapy to prevent or slow a decline in condition.

□   Other (describe):______________________________________________________

□     This patient requires: □ MSW consultation □ dietician consultation because: _____________________________


    Text Box: __/__/_ DATEText Box: PRINTED NAME




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