AHCA 5000-3008 PDF Details

The AHCA 5000 3008 form serves two primary purposes:

1. It certifies a patient's medical eligibility for long-term care services funded by Medicaid, either through the Institutional Care Program (ICP) or a Medicaid Home and Community-Based Services (HCBS) Waiver. The form can validate eligibility for a period of one year unless there's a significant change in the patient's condition.

2. It acts as a patient transfer form, providing comprehensive information about the patient's health status, primary diagnosis, risk factors, treatment details, physical and mental functionality, etc. It is used when a patient is being transferred between healthcare facilities or settings.

The form needs to be filled out completely and accurately by the attending healthcare professional, ensuring all mandatory sections (marked with an asterisk *) are completed. The form is then signed by a Florida licensed doctor of medicine or osteopathy, an Advanced Registered Nurse Practitioner (ARNP), or a Physician’s Assistant (PA), in accordance with Florida statutes and guidelines.

QuestionAnswer
Form Name Ahca 5000 3008 Form
Form Length 5 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 1 min 15 sec
Other names 3008 form, medicaid certification form, patient transfer form

Form Preview Example

Instructions for Completing the

Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form

1.The AHCA 5000-3008 form must be filled out in a complete and accurate manner.

2.If patient seeks eligibility for the Medicaid Institutional Care Program (ICP) or a Medicaid Home and Community-Based Services (HCBS) Waiver:

For the purposes of determining whether an individual meets the medical eligibility criteria, the Comprehensive Assessment and Review for Long-Term Care Services (CARES) program requires all applicable sections of this form be completed, however for Medicaid eligibility, CARES cannot accept this form if the items or sections marked by an asterisk (*) are not completed.

3.For Medicaid eligibility purposes, this form is good for one year from the date of the health care professional’s signature, unless there has been a significant change in the individual’s condition since the form was completed. CARES reserves the right to request new 3008’s in situations where there has been a significant change in the individuals condition or the form appears to be altered.,

NOTE: The AHCA 5000-3008 is an optional patient transfer form.

Page 1: Top of Page: *Patient’s Name, *Last 4 digits of the SSN and *DOB (Date of Birth) (*Required items)

A.*Patient Information: general demographic information about the patient, including primary language.

B.*Sight/*Hearing: note any visual impairments and any auditory impairments.

C.Decision Making Capacity (Patient): what is the decision-making capacity of the person listed as the patient?

D.*Emergency Contact: the names and phone numbers of the patient’s emergency contacts.

E.*Medical Condition: *Primary diagnosis: List the diagnosis that is considered to be primary for the individual. *Other diagnoses will include any other medical conditions the individual has been diagnosed with. If the individual is hospitalized at the time of completion, list the primary diagnosis at discharge, reason for transfer, and any surgical procedures performed during the hospital stay. If not enough room, list the primary diagnosis here and list the others on a separate page. Attach a medication reconciliation form and/or medication list that accurately notes medication history and those medications to be continued or stopped. Mandatory discussion of medications must be included in hand-off communication. (See section N.)

F.Infection Control Issues: note immunizations provided, PPD status, whether isolation precautions are required, and whether patient has any underlying infection.

G.*Patient Risk Alerts: *note any areas of risk, use of restraints, and allergies.

H.Advance Care Planning: note and attach any relevant documentation regarding patient’s health care wishes.

I.Transferred From: information on the facility transferring the patient, including facility name, transfer date, unit, the phone and fax numbers for that unit, the name of the discharge nurse and his/her direct contact number. The admit date and time are critical for determining Medicare coverage in the skilled nursing facility. The discharge date and time are important to the hospital for inpatient billing.

J.Transferred To: the name of the skilled nursing facility or other receiving facility where the patient is being transferred to, including the address, phone, and fax numbers.

K.Physician Contacts: the name and phone number of the patient’s primary care physician and, if applicable, the name and phone number of the hospitalist treating the patient during the recent hospital stay.

L.Time Sensitive Condition Specific Information: note whether patient has any specific critical conditions that require specialized care, or time sensitive medications due near time of transfer, and whether script was sent for controlled substance (if patient requires controlled substance, script must be sent with patient).

M.Pain Assessment: note the patient’s pain level and when medication was last administered, if applicable.

N.*Following Reports Attached: any of the following completed or available reports must be indicated, and attached to the AHCA MedServ-3008 form if appropriate and available (Medication list is not optional, and must be attached):

Physician Orders; Discharge Summary; Medication Reconciliation; Discharge Medication List; PASRR Forms: completed PASRR Level I and Level II (if required) – patient may not be admitted to a nursing facility prior to completion and authorization given for nursing facility placement; Social and Behavioral History; Treatment orders (indicate if wound care is included); Lab reports; X-rays; EKG; CT Scan; MRI; History & Physical.

*All Medications: If additional space is required to list all medications, attach a medications list to this form.

AHCA Form 5000-3008, (JUN 2016), incorporated by reference in Rule 59G-1.045, F.A.C.

Page 1 of 3

Instructions for Completing the

Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form

Page 2- Top of Page: *Patient’s Name, *Last 4 digits of the SSN and *DOB (Date of Birth) (*Required items)

O.Vital Signs: note vital signs along with the date and time taken.

P.*Patient Health Status: current state of patient as it relates to notation on *bladder and *bowel, as well as immunizations provided.

Q.*Nutrition / Hydration: list any special *dietary instructions, tube feeding information, supplements, and eating capabilities.

R.Treatments and Frequency: note which treatments are prescribed and the frequency.

S.*Physical Function: check physical capabilities of patient.

T.Skin Care – Stage & Assessment: note by number on the diagram the locations of any wounds, and list the corresponding stages for each location. List any other lesions or wounds.

U.*Mental / Cognitive Status at Transfer: indicate the cognitive status of the patient.

V.Treatment Devices: check if other devices are in place, and indicate corresponding dates, types, and settings.

W.Personal Items: check any personal items that are being sent with the patient;

X.Comments: add any comments here, sign, and print name; this is an optional field; may be signed by a nurse or social worker who enters the comments.

Y.*Physician Certification: this section must be completed and signed by a Florida licensed doctor of medicine or osteopathy, who holds a valid and active license pursuant to Chapters 458 and 459, Florida Statutes, and must include the physician’s printed name, title, Florida Medical License number, and contact telephone number.

NOTE: If within their scope of practice, this section may be signed by an advanced registered nurse practitioner (ARNP) who holds a valid and active license pursuant to Chapter 464, Florida Statutes.

NOTE: If delegated by the supervising physician in accordance with Chapters 458 and 459, Florida Statutes, and applicable Florida Administrative Code rules, this section may be signed by a physician’s assistant (PA).

NOTE: If the physician, ARNP, or PA is not licensed by the State of Florida but is similarly and appropriately licensed by the United States military, Veteran’s Affairs (VA), or another state in the United States of America, a copy of the physician, ARNP, or PA’s valid and current license must accompany the 3008 form.

NOTE: Any and all items that apply should be checked as appropriate; the physician, ARNP or PA should:

certify whether nursing facility services are required, and if the individual requires those services for the condition for which he/she received care during the hospitalization;

indicate whether the individual is in a community setting and is seeking long-term care services through a Medicaid Home and Community-Based Services (HCBS) Waiver, in lieu of certifying the need for nursing facility placement;

note the rehabilitation potential; and

include the effective date of the onset of the medical condition which requires nursing facility services. NOTE: If this is left blank, CARES will use the physician/ARNP/PA signature date for medical eligibility purposes for Medicaid programs.

Z.Person Completing Form: include the printed name and contact telephone number of the person completing the form. This is only required when the medical professional signing the form did not complete the form. Only individuals working with the medical professional who signed the form are allowed to complete this form.

Additional Notes:

1.Patient Name, last 4 digits of the SSN, and DOB must be completed on both pages.

WHY ARE WE ASKING FOR YOUR SOCIAL SECURITY NUMBER (SSN)? Federal law permits the State to use your social security number for screening and referral to programs or services that may be appropriate for you. 42 CFR § 435.910. We use the number to create a unique record for every individual that we serve, and the SSN ensures that every person we serve is identified correctly so that services are provided appropriately. Any information the State collects will remain confidential and protected under penalty of law. We will not use it or give it out for any other reason unless you have signed a separate consent form that releases us to do so or if required by law.

2.If this form is being used as a hospital transfer form, any area that does not pertain to the client’s current condition should be marked N/A.

3.Any section that can be addressed through documents should include the documents with the form and marked “See Attached” for the section.

AHCA Form 5000-3008, (JUN 2016), incorporated by reference in Rule 59G-1.045, F.A.C.

Page 2 of 3

Instructions for Completing the

Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form

4.Any changes after the provider has signed the form must be made by either the individual who signed the form (physician, ARNP, or PA) or another physician, PA, or ARNP. If someone other than the physician, ARNP, or PA makes a change, the physician, ARNP, or PA must also initial the change. If a provider other than the original provider makes changes they will initial any changes/additions, add their name, signature, Florida License number, and contact phone information in Section X.

AHCA Form 5000-3008, (JUN 2016), incorporated by reference in Rule 59G-1.045, F.A.C.

Page 3 of 3

On a proton pump inhibitor? Yes฀ No
If yes, was it for: In-hospital prophylaxis and can be discontinued
Specific diagnosis:
*Difficulty swallowing On one or more antibiotics? Yes No
*Seizures If yes, specify reason(s):
Any critical lab or diagnostic test pending at the time of discharge? Yes No If yes, please list:

MEDICAL CERTIFICATION FOR MEDICAID LONG-TERM CARE SERVICES AND PATIENT TRANSFER FORM

*Patient Name:

*A. PATIENT INFORMATION

 

 

*Gender:

Male

Female

 

 

*Hispanic Ethnicity:

Yes No

 

 

*Race: White

Black

Other:

 

 

 

*Language:

English

Other:

 

 

*B. SIGHT

 

 

HEARING

 

 

Normal

Impaired

Deaf Normal฀

Impaired

Blind

 

 

Hearing Aid฀฀฀

฀฀R

 

 

 

 

L

C. DECISION MAKING CAPACITY (PATIENT)

Capable to make healthcare decisions฀ Requires a surrogate

*D. EMERGENCY CONTACT

Name:

 

Name:

 

 

Phone:

Phone:

*E. MEDICAL CONDITION

 

 

 

*Primary฀diagnosis:

 

 

 

*Other฀diagnoses:

 

 

 

If฀Hospitalized:

Primary฀diagnosis฀at฀discharge:

Reason฀for฀transfer:

Surgical฀procedures฀performed:

F. INFECTION CONTROL ISSUES

PPD Status:฀ Positive฀ Negative Not known Screening date:

Associated Infections/resistant organisms:

MRSA

Site:

 

 

 

 

 

 

VRE

Site:

 

 

 

 

 

 

ESBL

Site:

 

 

 

 

 

 

MDRO

Site:

 

 

 

 

 

 

C-Diff

Site:

 

 

 

 

 

 

Other:

Site:

 

 

 

 

 

 

Isolation Precautions:

None

Contact

Droplet

Airborne

*G. PATIENT RISK ALERTS

 

 

 

 

*None Known

*Harm to self

*Elopement

*Harm to others

*Pressure Ulcers

*Falls

*Other:

 

 

 

 

 

 

 

 

RESTRAINTS: Yes฀ No

Types:

Reasons for use:

ALLERGIES: None Known Yes, List below:

Latex Allergy: Yes

No Dye Allergy/Reaction: Yes No

H. ADVANCE CARE PLANNING

 

 

Please ATTACH any relevant documentation:

 

Advance Directive

Yes

No

Living Will

Yes

No

DO NOT Resuscitate (DNR)

Yes

No

DO NOT Intubate

Yes

No

DO NOT Hospitalize

Yes

No

No Artificial Feeding

Yes

No

Hospice

Yes

No

*Last฀4฀SSN:

 

*DOB:

 

I. TRANSFERRED FROM

 

 

Facility Name:

 

 

 

Date:

 

Unit:

 

 

 

Phone:

 

Fax:

 

Discharge

 

 

 

Nurse:

 

Phone:

 

Admit Date:

 

Discharge Date:

 

Admit฀Time:

AM PM

Discharge฀Time:

AM฀ PM

J. TRANSFERRED TO

 

 

Facility Name:

 

 

 

Address 1:

 

 

 

Address 2:

 

 

 

Phone:

 

Fax:

 

K. PHYSICIAN CONTACTS

Primary Care Name:

Phone:

Hospitalist Name:

Phone:

L. TIME SENSITIVE CONDITION SPECIFIC INFORMATION

Medication due near time of transfer / list last time administered Script sent for controlled substances (attached):฀ Yes฀ No

Anticoagulants฀฀฀฀Date:

Time:

AM

PM

Antibiotics

Date:

Time:

AM

PM

Insulin

Date:

Time:

AM

PM

Other:

Date:

Time:

AM

PM

Has CHF diagnosis: Yes No

If yes; new/worsened CHF present on admission?

Yes No

 

 

Last echocardiogram: Date:

LVEF

%

 

 

 

 

 

M. PAIN ASSESSMENT:

 

 

 

 

Pain Level (between 0 - 10):

Time:

AM

 

 

 

 

Last administered: Date:

 

 

 

PM

 

 

 

 

 

 

 

*N.฀FOLLOWING฀REPORTS฀ATTACHED

 

 

 

Physicians Orders

Treatment Orders

Discharge Summary฀

Includes Wound Care

Medication Reconciliation

Lab reports

 

 

 

Discharge Medication List

X-ray

EKG

PASRR Forms

CT Scan

MRI

Social and Behavioral History

History฀&฀Physical

*ALL MEDICATIONS: (MUST ATTACH LIST)

AHCA Form 5000-3008, (JUN 2016)

, incorporated by reference in Rule 59G-1.045, F.A.C.฀

*Data฀required฀for฀Medicaid

MEDICAL CERTIFICATION FOR MEDICAID LONG-TERM CARE SERVICES AND PATIENT TRANSFER FORM฀

*Patient Name:฀

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Last฀4฀SSN:

 

 

 

 

 

*DOB:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

O. VITAL SIGNS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

T. SKIN CARE – STAGE & ASSESSMENT

 

 

 

 

Date:

 

 

 

Time Taken:

 

 

 

 

 

 

 

 

AM

PM

 

 

 

 

 

 

 

 

 

 

 

 

Pressure Ulcers

 

 

 

 

HT:

FEET

 

INCHES

WT:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Indicate stage and location(s) of

 

Temp:

 

 

 

 

 

BP:

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

lesions using corresponding number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HR:

 

 

 

 

RR:

 

 

 

 

 

 

Sp02:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*P. PATIENT HEALTH

STATUS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

 

 

 

 

 

*Bladder:

Continent

Incontinent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

 

 

 

Ostomy

Catheter Type:

 

 

 

 

 

date฀inserted:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Foley Catheter:

 

Yes฀

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List any other lesions or wounds:

 

 

 

No

If฀yes,฀date฀inserted:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Indications for use:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Urinary retention due to:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Monitoring intake and output

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*U.฀MENTAL฀/฀COGNITIVE฀STATUS฀AT฀TRANSFER

 

 

 

Skin Condition:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Alert,฀oriented,฀follows฀instructions

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Alert,฀disoriented,฀but฀can฀follow฀simple฀instructions฀

 

Attempt to remove catheter made in hospital?

Yes

No

 

Alert,฀disoriented,฀and฀cannot฀follow฀simple฀instructions฀

 

Date Removed:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Not฀Alert

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Bowel:

 

Continent฀

Incontinent฀

 

Ostomy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Last BM:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V. TREATMENT฀DEVICES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Heparin฀Lock฀-฀Date฀changed:

 

 

 

 

 

 

Immunization status:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IV฀/฀PICC฀/฀Portacath฀Access฀-฀Date฀inserted:

 

Influenza:

 

 

 

Yes

 

No

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pneumococcal:

 

Yes

 

No

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Internal Cardiac Defibrillator

Pacemaker

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Q. NUTRITION / HYDRATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Wound Vac

 

 

 

 

 

 

 

 

 

 

 

 

 

*Dietary Instructions:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Respiratory - Delivery Device:

CPAP

 

 

BiPAP

 

Tube Feeding:

G-tube J-tube

 

PEG

 

 

 

 

 

 

 

 

 

 

 

 

Insertion Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nebulizer

 

 

 

Other:

 

 

 

 

 

 

 

 

Nasal Cannula

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Supplements (type):

TPN

Other Supplements:

 

 

 

 

 

 

Mask: Type

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Oxygen - liters:

%

 

 

PRN

Continuous

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Eating:

Self

 

Assistance

Difficulty Swallowing

 

 

 

 

 

Trach Size:

 

 

 

 

 

 

Type:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ventilator Settings:

 

 

 

 

 

 

 

 

 

 

 

 

 

R. TREATMENTS AND FREQUENCY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PT - Frequency:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Suction

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OT - Frequency:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

W. PERSONAL ITEMS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Artificial Eye

 

 

 

 

 

Prosthetic

Walker

 

 

 

Speech - Frequency:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contacts

 

 

 

 

 

 

 

 

 

 

Cane

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

฀฀฀฀Dialysis - Frequency:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Eyeglasses

 

 

 

 

 

Crutches

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*S. PHYSICAL FUNCTION Ambulation:

 

 

 

 

 

 

 

 

 

Dentures

 

 

 

 

 

 

 

 

 

 

Hearing Aids

 

 

 

 

*Ambulation:

 

 

 

 

 

 

 

 

*Transfer:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

U

L

Partial

 

 

L

R

 

 

 

 

 

 

Not ambulatory

 

 

 

 

 

 

 

 

 

Self

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

X. COMMENTS (Optional)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ambulates independently

 

 

 

 

 

Assistance฀

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ambulates with assistance

 

 

 

 

 

1 Assistant฀

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ambulates with assistive device

 

 

 

 

2 Assistants

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Devices:

 

 

 

 

 

 

 

 

 

 

Weight-bearing:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Wheelchair (type):

 

 

 

 

 

 

Left:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Appliances:

 

 

 

 

 

 

 

 

 

 

 

Full

Partial

None

Signature:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Prosthesis:

 

 

 

 

 

 

 

 

Right:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lifting Device:

 

 

 

 

 

 

 

 

 

 

 

Full

Partial

None

Printed Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Y.PHYSICIAN CERTIFICATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*I certify the individual requires nursing facility (NF) services.

The฀individual฀received฀care฀for฀this฀condition฀during฀hospitalization.

*I certify the individual is in need of Medicaid Waiver Services in lieu of nursing facility placement.

Rehab Potential (check one) Good Fair Poor

*Effective date of medical condition:

*Physician/ARNP/PA฀License฀#:

*Physician/ARNP/PA฀Signature:

 

 

 

 

*Date:

 

*Printed฀Physician/ARNP/PA฀Name฀&฀Title:

 

 

*Phone Number:

 

Z.฀PERSON฀COMPLETING฀FORM

Name:

 

 

Phone Number:

 

Date:

 

 

 

 

 

 

 

AHCA Form 5000-3008, (JUN 2016)

, incorporated by reference in Rule 59G-1.045, F.A.C.

* Sections฀required฀for฀Medicaid

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1. While completing the PICC, make certain to include all essential blank fields within its associated section. It will help to expedite the work, making it possible for your details to be processed swiftly and appropriately.

How one can fill out DNR portion 1

2. Once your current task is complete, take the next step – fill out all of these fields - L TIME SENSITIVE CONDITION, AnticoagulantsDate Antibiotics, Time Time Time Time, Has CHF diagnosis If yes, Yes, Yes, Last echocardiogram Date, LVEF, On a proton pump inhibitor If yes, Yes, Inhospital prophylaxis and can be, IfHospitalized, Negative, Not known, and MRSA VRE ESBL MDRO CDiff Other with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Yes, L TIME SENSITIVE CONDITION, and Not known inside DNR

3. Completing Reasons for use, ALLERGIES, None Known, Yes List below, Latex Allergy, Yes, Dye AllergyReaction, Yes, H ADVANCE CARE PLANNING Please, Advance Directive Living Will DO, Yes Yes Yes Yes Yes Yes Yes, No No No No No No No, M PAIN ASSESSMENT Pain Level, Time, and AM PM is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Completing segment 3 in DNR

4. This next section requires some additional information. Ensure you complete all the necessary fields - MEDICAL CERTIFICATION FOR MEDICAID, Patient Name O VITAL SIGNS Date, Time Taken, HT Temp, FEET, INCHES, HR P PATIENT HEALTH STATUS Bladder, Catheter Type, Continent, Incontinent, Sp, dateinserted, LastSSN T SKIN CARE STAGE , DOB, and Pressure Ulcers Indicate stage and - to proceed further in your process!

Part number 4 in completing DNR

When it comes to FEET and Incontinent, be certain that you don't make any mistakes in this section. Both of these are the key fields in this PDF.

5. To conclude your document, the particular area features a number of extra blank fields. Entering Attempt to remove catheter made in, Internal Cardiac Defibrillator, Gtube, Jtube, PEG, Respiratory Delivery Device, CPAP, BiPAP Nasal Cannula, Tube Feeding Insertion Date, TPN, Other Supplements, Eating R TREATMENTS AND FREQUENCY, Assistance, Self, and Difficulty Swallowing will certainly finalize everything and you can be done in a tick!

How one can fill in DNR stage 5

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