Plan of care or worksheet (optional) All orders for the 60 day episode. A worksheet may be used by Agency to develop the Plan of Care. X *Once the comprehensive assessment is completed (within five days of the initial visit) and the plan of care is approved by the responsible physician, the *documents must be provided to the patient and/or their representative. If therapy and/or social work services are ordered, their evaluation visit will be made within four days of referral or as ordered. Documentation that is submitted will be reviewed for thoroughness, completeness, and skill. If it is incorrect, the Agency will contact the staff person to correct it as soon as possible. Documentation Consent Form The purpose of this form is to obtain consent to treat, release medical records and bill for services. It also serves to document patient/client education regarding financial obligation, patient/client rights, Advance Directives, and the complaint procedure. It should be filled out completely. The consent is signed/witnessed by agency staff. If someone other than the patient/client signs the consent, there should be an explanation of the relationship and why the patient/client is unable to sign. 42 CFR §484.50(b) Exercise of Rights states: • §484.50(b)(1) If a patient has been adjudged to lack legal capacity to make health care decisions as established by state law by a court of proper jurisdiction, the rights of the patient may be exercised by the person appointed by the state court to act on the patient’s behalf. • §484.50(b)(2) If a state court has not adjudged a patient to lack legal capacity to make health care decisions as defined by state law, the patient’s representative may exercise the patient’s rights. • §484.50(b)(3) If a patient has been adjudged to lack legal capacity to make health care decisions under state law by a court of proper jurisdiction, the patient may exercise his or her rights to the extent allowed by court order. Comprehensive Assessment Regulation requires the OASIS data set to be incorporated with the clinical assessment to be a comprehensive assessment. See Section 7. OASIS for details. The following policy includes required content of the comprehensive assessment. Review the following policy and procedure: Online Bookmark Title of Policy Provision of Care (PC) Initial Patient/Client Comprehensive Assessment
