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Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission [52748-1]

Date Done

Time Done

Where Done

Comment

Name

Value

Units

Administrative Items [52452-0]

Assessment Type [52453-8]

Reason for assessment [52454-6]

Assessment reference date - observation end date [54593-9]

Provider Information [52457-9]

Provider's Name [52458-7]

Patient information [52460-3]

Patient's First Name [45392-8]

Patient's Middle Initial or Name [52461-1]

Patient's Last Name [45394-4]

Patient's Nickname (optional) [52462-9]

Patient's Medicare Health Insurance Number [45397-7]

Patient's Medicaid Number [45400-9]

Patient's Facility/Agency Identification Number (for internal tracking) [52463-7]

Admission date [52455-3]

Birth date [21112-8]

Social Security # [45396-9]

Gender [46098-0]

Race or ethnicity [46463-6]

Is English the patient's primary language? [52553-5]

If English is not the patient's primary language, what is the patient's primary language? [52554-3]

Interpreter needed [54588-9]

Current Payment Source (s) [52556-8]

Other (specify) [52721-8]

Admission information - home health [69352-3]

Pre-admission Service Use [52537-8]

Admitted From. Immediately preceding this admission, where was the patient? [52722-6]

Other (specify) [52723-4]

If admitted from a medical setting, what was the primary diagnosis being treated in the previous setting? [52724-2]

In the last 2 months, what medical services other than those identified in A1. has the patient received? [52725-9]

Within this acute care hospital stay, on what other units has the patient been treated prior to coming to this unit? [70129-2]

Patient History Prior to this Current Illness, Exacerbation, or Injury [52538-6]

Prior to this recent illness, where did the patient live? [52726-7]

If the patient lived in the community prior to this illness, provide the patient's zip code (if the patient 's residence was in U.S.). [52539-4]

Lives outside U.S. [52727-5]

ZIP Code unknown [52540-2]

If the patient lived in the community prior to this illness, what help was used? [52541-0]

If the patient lived in the community prior to this illness, who did the patient live with? [52542-8]

If the patient lived in the community prior to this current illness, exacerbation, or injury, are there any structural barriers in the patient's prior residence that could interfere with the patient's discharge? [52543-6]

Other (specify) [52544-4]

Prior Functioning. Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury. [52449-6]

Self Care: Did the patient need help bathing, dressing, using the toilet, or eating? [52545-1]

Indoor Mobility (Ambulation): Did the patient need assistance with walking from room to room (with or without devices such as cane, crutch, or walker)? [52546-9]

Stairs (Ambulation): Did the patient need assistance with internal or external stairs (with or without devices such as cane, crutch, or walker)? [52547-7]

Indoor Mobility (Wheelchair): Did the patient need assistance with moving from room to room using a wheelchair, scooter, or other wheeled mobility device? [52548-5]

Functional Cognition: Did the patient need help planning regular tasks, such as shopping or remembering to take medication? [52549-3]

Mobility devices and aids used prior to current illness, exacerbation, or injury [52550-1]

Other (specify) [52551-9]

Falls in the past Y [52552-7]

Frequency of Assistance at Admission for Home Health. How often will the patient require assistance (physical care or supervision) from a caregiver(s) or provider(s)? [55754-6]

Willing Caregiver(s). Does the patient have one or more willing caregiver(s)? [52691-3]

Types of Caregiver(s). What is the relationship of the caregiver(s) to the patient? [52692-1]

Residential Information [55755-3]

Upon admission, who does the patient live with? [55756-1]

Support Needs &or Caregiver Assistance [52528-7]

ADL assistance (e.g., transfer/ambulation, bathing, dressing, toileting, eating/feeding) [52694-7]

IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances) [52695-4]

Medication administration (e.g., oral, inhaled, or injectable) [52696-2]

Medical procedures/treatments (e.g., changing wound dressing) [52697-0]

Management of equipment (includes oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment, or supplies) [52698-8]

Supervision and safety [52699-6]

Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) [52700-2]

None of the above or non-residential setting [52701-0]

Current medical information [69377-0]

Primary and Other Diagnoses, Comorbidities, and Complications [52464-5]

Primary Diagnosis at Assessment [18630-4]

Other Diagnoses, Comorbidities, and Complications [52465-2]

Dx [29308-4]

Which of the following treatments did the patient receive during the 2-day assessment period? [52468-6]

Major treatments admitted with [52802-6]

Specify reason for continuous monitoring: [52565-9]

Specify most intensive frequency of suctioning during stay: Every____ hours [52566-7]

Specify reason for 24-hour supervision [52567-5]

Specify [52568-3]

Medications (Optional) [52471-0]

Medication Name [52418-1]

Dose form Medication.current [52809-1]

Route [18609-8]

Frequency [52810-9]

Planned Stop Date (if applicable) [52796-0]

Allergies & Adverse Drug Reactions (Optional for Home Health Admission.) [52472-8]

Does patient have allergies or any known adverse drug reactions? [52571-7]

Allergies/Causes of Reaction [52473-6]

Patient Reaction [31044-1]

Skin integrity panel [52474-4]

Presence of pressure ulcers [52475-1]

Is this patient at risk of developing pressure ulcers? [52573-3]

Does this patient have one or more unhealed pressure ulcer(s) at stage 2 or higher? [52574-1]

IF THE PATIENT HAS ONE OR MORE STAGE 2-4 PRESSURE ULCERS, indicate the number of unhealed pressure ulcers at each stage. [55763-7]

Number of pressure ulcers at assessment - stage 2 [52575-8]

Number of pressure ulcers at assessment - stage 3 [52576-6]

Number of pressure ulcers at assessment - stage 4 [52577-4]

Number of pressure ulcers at assessment - unstageable [52578-2]

Number of unhealed stage 2 ulcers known to be present for more than 1 month [52583-2]

If any pressure ulcer is stage 3 or 4 (or if eschar is present), please record the most recent measurements for the LARGEST ulcer (or eschar): [52477-7]

Longest length in any direction [52728-3]

Pressure Ulcer Width: [52729-1]

Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the depth of the deepest area [57228-9]

Date of measurement [52584-0]

Indicate if any unhealed stage 3 or stage 4 pressure ulcer(s) has undermining and/or tunneling (sinus tract) present. [52730-9]

Major wound (excluding pressure ulcers). Does the patient have one or more major wound(s) that require ongoing care because of draining, infection, or delayed healing? [52585-7]

Number of Major Wounds [52478-5]

Delayed healing of surgical wound [52586-5]

Trauma-related wound [52587-3]

Diabetic foot ulcer(s) [52588-1]

Vascular ulcer (arterial or venous including diabetic ulcers not located on the foot) [52589-9]

Other [52590-7]

Please specify: [52591-5]

Turning surfaces not intact [52592-3]

Physiologic Factors [52479-3]

Anthropometric Measures [52480-1]

Height (inches) OR [3137-7]

Height (cm) [8301-4]

Weight (pounds) OR [3141-9]

Weight (kg) [8335-2]

Vital signs & oximetry - admission, home health, interim, discharge [72105-0]

Temperature (deg F) OR [8310-5]

Heart Rate (beats/min) [8867-4]

Respiratory Rate (breaths/min) [9279-1]

Systolic Blood Pressure (mm/Hg) [8480-6]

Diastolic Blood Pressure (mm/Hg) [8462-4]

SaO2 % BldA PulseOx [59408-5]

Please specify source and amount of supplemental O2 [52593-1]

Laboratory [52482-7]

Hemogloblin (gm/dL) [718-7]

Hematocrit (%) [20570-8]

WBC (K/mm3) [26464-8]

HbA1c (%) [4548-4]

Sodium (mEq/L) [2947-0]

Potassium (mEq/L) [6298-4]

BUN (mg/dL) [3094-0]

Creatinine (mg/dL) [2160-0]

Albumin (gm/dL) [1751-7]

Prealbumin (mg/dL) [14338-8]

INR [6301-6]

Other [52483-5]

Left Ventricular Ejection Fraction (%) [10230-1]

Arterial Blood Gases (ABGs) [52484-3]

Please specify source and amount of supplemental O2 [52593-1]

pH BldA [2744-1]

PaCO2 (mm/Hg) [2019-8]

HCO3 (mEq/L) [1960-4]

PaO2 (mm/Hg) [2703-7]

SaO2 (%) [2708-6]

B.E. (base excess) (mEq/dL) [1925-7]

Pulmonary Function Tests [52485-0]

FVC (liters) [19870-5]

FEV1% or FEV1/FVC (%) [19926-5]

FEV1 (liters) [20150-9]

PEF (liters per minute) [33452-4]

MVV (liters per minute) [20159-0]

TLC (liters) [19862-2]

FRC (liters) [19843-2]

RV (liters) [20146-7]

ERV (liters) [19924-0]

Influenza vaccine [69339-0]

Influenza virus vaccine received in facility [55019-4]

Flu vaccine date [58131-4]

If influenza vaccine not received, state reason: [55020-2]

Pneumococcal vaccine [55021-0]

Is the resident's Pneumococcal Vaccination up to date? [55022-8]

Reason pneumococcal vaccine not received [45956-0]

Cognitive Status, Mood and Pain [52487-6]

Comatose [55762-9]

Persistent vegetative state/no discrenible consciousness at the time of admission [45482-7]

Temporal Orientation &or Mental Status [52488-4]

Interview Attempted [52489-2]

Interview attempted [52594-9]

Indicate reason that the interview was not attempted [52595-6]

Brief interview for mental status [69966-0]

Repetition of three words [52731-7]

Year, Month, Day [52492-6]

Temporal orientation - current year [52732-5]

Temporal orientation - current month [52733-3]

Temporal orientation - current day of the week [54609-3]

Recall [52493-4]

Able to recall "sock" [52735-8]

Able to recall "blue" [52736-6]

Able to recall "bed" [52737-4]

Observational Assessment of Cognitive Status [52494-2]

Memory/recall ability [52596-4]

Specify reason [52597-2]

Confusion Assessment Method (CAM) [52495-9]

Inattention [52738-2]

Disorganized thinking [52739-0]

Altered level of consciousness/alertness [52740-8]

Psychomotor retardation [52741-6]

Has the patient exhibited any of the following behaviors during the 2-day assessment period? [52496-7]

Physical behavioral symptoms directed toward others [52598-0]

Verbal behavioral symptoms directed towards others [52599-8]

Other disruptive or dangerous behavioral symptoms not directed towards others, including self-injurious behaviors [52600-4]

Mood [52497-5]

Mood Interview Attempted? [52601-2]

Patient health questionnaire 2 item [52498-3]

Little interest or pleasure in doing things [44250-9]

Little interest or pleasure in doing things in last 2W.frequency [54637-4]

Feeling down, depressed, or hopeless [44255-8]

Feeling down, depressed or hopeless in last 2W.frequency [54639-0]

Feeling sad [52499-1]

Ask patient: "During the past 2 weeks, how often would you say, 'I feel sad'?" [52602-0]

Pain [52500-6]

Pain Interview Attempted? [52603-8]

Pain Presence. Ask patient: "Have you had pain or hurting at any time during the last 2 days?" [52604-6]

Pain Severity. Ask patient: "Please rate your worst pain during the last 2 days on a zero to 10 scale, with zero being no pain and 10 as the worst pain you can imagine." [52742-4]

Pain Effect on Sleep. Ask patient: "During the past 2 days, has pain made it hard for you to sleep?" [52605-3]

Pain Effect on Activities. Ask patient: "During the past 2 days, have you limited your activities because of pain?" [52606-1]

Pain Observational Assessment. If the patient could not be interviewed for pain assessment, check all indicators of of pain or possible pain [52607-9]

Impairments [52502-2]

Bladder and Bowel Management - Use of Device(s) and Incontinence [52503-0]

Does the patient have any impairments with bladder or bowel management (e.g., use of a device or incontinence)? [52608-7]

Bladder - Does this patient use an external or indwelling device or require intermittent catheterization? [52609-5]

Bowel - Does this patient use an external or indwelling device or require intermittent catheterization? [52610-3]

Bladder - Indicate the frequency of incontinence. [52611-1]

Bowel - Indicate the frequency of incontinence. [52612-9]

Bladder - Does the patient need assistance to manage equipment or devices related to bladder or bowel care (e.g., urinal, bedpan, indwelling catheter, intermittent catheterization, ostomy, incontinence pads/undergarments)? [52613-7]

Bowel - Does the patient need assistance to manage equipment or devices related to bladder or bowel care (e.g., urinal, bedpan, indwelling catheter, intermittent catheterization, ostomy, incontinence pads/undergarments)? [52614-5]

Bladder - If the patient is incontinent or has an indwelling device, was the patient incontinent (excluding stress incontinence) immediately prior to the current illness, exacerbation, or injury? [52615-2]

Bowel - If the patient is incontinent or has an indwelling device, was the patient incontinent (excluding stress incontinence) immediately prior to the current illness, exacerbation, or injury? [52616-0]

Swallowing [52504-8]

Does the patient have any signs or symptoms of a possible swallowing disorder? [52618-6]

Other (specify) [52619-4]

Describe the patient's usual ability with swallowing. [52620-2]

Hearing, Vision, and Communication [52505-5]

Does the patient have any impairments with hearing, vision, or communication? [52621-0]

Understanding verbal content - excluding language barriers [52622-8]

Expression of ideas and wants [52623-6]

Ability to see in adequate light (with glasses or other visual appliances) [52624-4]

Ability to hear (with hearing aid or hearing appliance, if normally used) [52625-1]

Medication management-oral medications during 2D assessment period [52677-2]

Medication management-injectable medications during 2D assessment period [52679-8]

Weight-bearing [52506-3]

Does the patient have any clinician-ordered weight-bearing or limb/spinal loading restrictions( including upper body lift, push, pull, or carry restrictions)? [52626-9]

Weight-bearing restrictions panel [52507-1]

Upper Extremity - Left [52627-7]

Upper Extremity - Right [52628-5]

Lower Extremity - Left [52629-3]

Lower Extremity - Right [52630-1]

Grip Strength [52508-9]

Does the patient have any impairments with grip strength (e.g. reduced/limited or absent)? [52631-9]

Grip strength panel [52509-7]

Left Hand [52632-7]

Right Hand [52633-5]

Respiratory status [52510-5]

Does the patient have any impairments with respiratory status? [52634-3]

Respiratory status with supplemental oxygen [52635-0]

Respiratory status without supplemental oxygen [52636-8]

Endurance [52511-3]

Does the patient have any impairments with endurance? [52637-6]

Mobility Endurance: Was the patient able to walk or wheel 50 feet (15 meters)? [52638-4]

Sitting Endurance: Was the patient able to tolerate sitting for 15 minutes? [52639-2]

Mobility devices and aids needed [52512-1]

Indicate all mobility devices and aids needed at time of assessment. [52640-0]

Other (specify) [52641-8]

Functional Status - Usual Performance [52513-9]

Core Self Care [52514-7]

Eating [52642-6]

Tube feeding [52643-4]

Oral hygiene [52644-2]

Toilet hygiene [52645-9]

Upper body dressing [52646-7]

Lower body dressing [52647-5]

Core Functional Mobility [52515-4]

Lying to Sitting on Side of Bed [52648-3]

Sit to Stand [52649-1]

Chair/Bed-to-Chair Transfer [52650-9]

Toilet Transfer [52651-7]

Mode of Mobility - All Patients [52516-2]

Does this patient primarily use a wheelchair for mobility? [52652-5]

Select the longest distance the patient walks and code his/her level of independence (Level 1-6) on that distance. Observe performance. (Select only one.) [52517-0]

Walk 150 ft (45 m) [52653-3]

Walk 100 ft (30 m) [52654-1]

Walk 50 ft (15m) [52655-8]

Walk in Room Once Standing [52656-6]

Select the longest distance the patient wheels and code his/her level of independence (Level 1-6). Observe performance. (Select only one.) [52518-8]

Wheel 150 ft (45 m) [52657-4]

Wheel 100 ft (30 m) [52658-2]

Wheel 50 ft (15 m) [52659-0]

Wheel in Room Once Seated [52660-8]

Supplemental Functional Ability [52519-6]

Following discharge, is it anticipated that the patient will need post-acute care to improve their functional ability or other types of personal assistance? [54066-6]

Wash Upper Body [52661-6]

Shower/bathe self [52662-4]

Roll left and right [52663-2]

Sit to lying [52664-0]

Picking up object [52665-7]

Putting on &or taking off footwear during 2D assessment period [52666-5]

Mode of Mobility - PAC Patients [52520-4]

Does this patient primarily use a wheelchair for mobility? [52652-5]

1 step (curb) [52667-3]

Walk 50 feet with two turns [52668-1]

12 steps-interior [52669-9]

Four steps-exterior [52670-7]

Walking 10 feet on uneven surfaces [52671-5]

Car transfer [52672-3]

Wheel short ramp [52673-1]

Wheel long ramp [52674-9]

Telephone answering [52675-6]

Telephone-placing call [52676-4]

Medication management-oral medications [52677-2]

Medication management-inhalant/mist [52678-0]

Medication management-injectable medications [52679-8]

Make light meal [52680-6]

Wipe down surface [52681-4]

Light shopping [52682-2]

Laundry [52683-0]

Use public transportation [52684-8]

Overall Plan of Care &or Advance Care Directives panel [81957-3]

Overall Plan of Care/Advance Care Directives [52522-0]

Have the patient (or representative) and the care team (or physician) documented agreed-upon care goals and expected dates of completion or re-evaluation? [52685-5]

Which description best fits the patient's overall status? [52686-3]

In anticipation of serious clinical complications, has the patient made care decisions which are documented in the medical record? [52687-1]

Medical coding information [69351-5]

Principal Diagnosis [52534-5]

ICD-9 CM for Principal Diagnosis at Assessment [46584-9]

Primary Dx ICD code [86255-7]

Diagnosis.primary [18630-4]

Dx [29308-4]

Other Diagnoses, Comorbidities, and Complications [52807-5]

Dx ICD code [52797-8]

Dx [29308-4]

Other useful information [52535-2]

Is there other useful information about this patient that you want to add? [52720-0]

PLEASE WAIT