Basic Info

Name : first_name.' '.$datas->last_name?>
Birth : dob?>
Email : patient_email?>
Soc Sec No : soc_sec_no?>

Gender : gender?>
Marital : marital_stat?>
Weight : weight?> lbs
height);$Htf = $HtFI[0];$Hti = $HtFI[1];?>
Height : feet inch

address); ?>
Address : address, $pAdata->Apartment.", ".$pAdata->City.", ".$pAdata->County.", ".$pAdata->State.", ".$pAdata->Zipcode?>
Direction : direction){echo $datas->direction;}else{echo "NA";}?>

Patient Info

Designate First Name : designate_first_name){echo $datas->designate_first_name;}else{echo "NA";}?>
Designate Last Name : designate_last_name){echo $datas->designate_last_name;}else{echo "NA";}?>
Designate Telephone : designate_telephone){echo $datas->designate_telephone;}else{echo "NA";}?>
Designate Cell : designate_cell){echo $datas->designate_cell;}else{echo "NA";}?>
Level of Care : level_of_care){echo $datas->level_of_care;}else{echo "NA";}?>
Referal Source : reference_information){echo $datas->reference_information;}else{echo "NA";}?>
EVV Verification : evv_verification){echo $datas->evv_verification;}else{echo "NA";}?>
Primary Nurse : primary_nurse){echo $datas->primary_nurse;}else{echo "NA";}?>
Intake Nurse : intake_nurse?> intake_nurse){echo $datas->intake_nurse;}else{echo "NA";}?>

Care Info

Level of Service Need : level_of_service){ if($datas->level_of_service==4){ echo "RN"; }if($datas->level_of_service==5){ echo "LPN"; }if($datas->level_of_service==6){ echo "HHA"; }if($datas->level_of_service==7){ echo "PCA"; } }else{ echo "NA"; } ?>
New Order : new_order){echo $datas->new_order;}else{echo "NA";}?>
Service Activity Needed : serviceName){ echo $datas->serviceName; } else{ echo "NA"; } ?>
Type Of Access : type_access){ // echo $datas->type_access; echo $datas->type_of_accesss; }else{ echo "NA"; } ?>
Patient Seen By Md : patient_seen_by_MD){echo $datas->patient_seen_by_MD;}else{echo "NA";}?>
Current Lab Work : current_lab_work){echo $datas->current_lab_work;}else{echo "NA";}?>
Lab Order : lab_order){echo $datas->lab_order;}else{echo "NA";}?>
Additional Lab Order : other_lab_frequency){echo $datas->other_lab_frequency;}else{echo "NA";}?>
Lab Frequency : lab_frequency){echo $datas->lab_frequency;}else{echo "NA";}?>
Other Lab Frequency : other_lab_frequency){echo $datas->other_lab_frequency;}else{echo "NA";}?>
Tube : tube_type){echo $datas->tube_type;}else{echo "NA";}?>
Formula : formula){echo $datas->formula;}else{echo "NA";}?>
Schedule : schedule){echo $datas->schedule;}else{echo "NA";}?>
Flush With : flush_with){echo $datas->flush_with;}else{echo "NA";}?>
Daily Intake Requirment : daily_intake_requirment){echo $datas->daily_intake_requirment;}else{echo "NA";}?>
Flush Frequency : flush_frequency){echo $datas->flush_frequency;}else{echo "NA";}?>
Flush Restrictions : referral_source){echo $datas->referral_source;}else{echo "NA";}?>
Flush Restriction Amount : fluide_restric_amount){echo $datas->fluide_restric_amount;}else{echo "NA";}?>

Insurance Info

Basic

Insurance Type : insurance_type){echo $dataIns->insurance_type;}else{echo "NA";}?>
Insurance Plan : insurance_plan){echo $dataIns->insurance_plan;}else{echo "NA";}?>
insurance_type == 'Madicaid') { ?>
Medicaid Id : medicaid_id){echo $dataIns->medicaid_id;}else{echo "NA";}?>
Medicaid Pedriatic : medicaid_pedriatic){echo $dataIns->medicaid_pedriatic;}else{echo "NA";}?>
Medicaid Adult : medicaid_adult){echo $dataIns->medicaid_adult;}else{echo "NA";}?>
Type : primaryOrSecondary){echo $dataIns->primaryOrSecondary;}else{echo "NA";}?>
Policy NO : Pvt_Ins_PlanId_Policy_no){echo $dataIns->Pvt_Ins_PlanId_Policy_no;}else{echo "NA";}?>
Claim No : claim_no){echo $dataIns->claim_no;}else{echo "NA";}?>

Emergency Contact

Name : emgContactFirstName && $dataIns->emgContactLastName) {echo $dataIns->emgContactFirstName." ".$dataIns->emgContactLastName;}else{echo "NA";} ?>
Relationship to the Patient : id==$dataIns->emgContactRelation){ echo $relation->name; } } ?>
emgContactAddress);?>
Address :
  • House/Street : address;?>
  • Apartment : Apartment;?>
  • City : City;?>
  • State : State;?>
  • Zipcode : Zipcode;?>
  • County: County;?>
Telephone : emgContactTelephone){echo $dataIns->emgContactTelephone;}else{echo "NA";}?>
Cellphone : emgContactCellNo){echo $dataIns->emgContactCellNo;}else{echo "NA";}?>
Other Number : emgContactOteNo){echo $dataIns->emgContactOteNo;}else{echo "NA";}?>
Email : emgContactEmail){echo $dataIns->emgContactEmail;}else{echo "NA";}?>
Lives with Patient : emgContactLiveswithPatient){echo $dataIns->emgContactLiveswithPatient;}else{echo "NA";}?>
Home access : emgContactAccessToHome){echo $dataIns->emgContactAccessToHome;}else{echo "NA";}?>

Emergency Preparedness

Evacutaion zone : EmgPrepdEvacZone){echo $dataIns->EmgPrepdEvacZone;}else{echo "NA";}?>
Mobility Status : EmgPrepdMobilityStat){echo $dataIns->EmgPrepdMobilityStat;}else{echo "NA";}?>
Evacuation Location : EmgPrepdLocation){echo $dataIns->EmgPrepdLocation;}else{echo "NA";}?>
Electrical Equipment Dependency : EmgPrepdEleDependency){echo $dataIns->EmgPrepdEleDependency;}else{echo "NA";}?>

Diaganosis

ICD : diagonosisICD){echo $dataIns->diagonosisICD;}else{echo "NA";}?>
Date : diagonosisHistoricalDate){echo $dataIns->diagonosisHistoricalDate;}else{echo "NA";}?>
Historical data Diaganosis : diagonosisData){echo $dataIns->diagonosisData;}else{echo "NA";}?>
Type : diagonosisPrimary){echo $dataIns->diagonosisPrimary;}else{echo "NA";}?>

Clinical Information

Start Of Care : ClinicalStartOfCare){echo $dataIns->ClinicalStartOfCare;}else{echo "NA";}?>
Allergies : ClinicalAllergies){echo $dataIns->ClinicalAllergies;}else{echo "NA";}?>
Allergic Reaction : ClinicalAllergiesReaction){echo $dataIns->ClinicalAllergiesReaction;}else{echo "NA";}?>
Notes : ClinicalNotes){echo $dataIns->ClinicalNotes;}else{echo "NA";}?>

Physican and MD information

Name : PhysicanName){echo $dataIns->PhysicanName;}else{echo "NA";}?>
Address : PhysicanAddress){echo $dataIns->PhysicanAddress;}else{echo "NA";}?>
Telephone : PhysicanTelephone){echo $dataIns->PhysicanTelephone;}else{echo "NA";}?>
Email : PhysicanEmail?> PhysicanEmail){echo $dataIns->PhysicanEmail;}else{echo "NA";}?>
Affiliation : PhysicanAffiliation){echo $dataIns->PhysicanAffiliation;}else{echo "NA";}?>
FAX : PhysicanFax){echo $dataIns->PhysicanFax;}else{echo "NA";}?>
NPI : PhysicanNPI){echo $$dataIns->PhysicanNPI;}else{echo "NA";}?>
Lisence : PhysicanLisence){echo $dataIns->PhysicanLisence;}else{echo "NA";}?>
Note : PhysicanNote){echo $dataIns->PhysicanNote;}else{echo "NA";}?>

Annual In-Home Performance Evaluation

Name :
Title :
Date of Hire :
Date of Visit :
Time of Visit :
Treatments/Procedures Observed :
Comments/Recommendations :
Name of Supervisor :
Supervisor Title :
Demonstrates respect for patients rights, privacy and confidentiality :
Comments :
Demonstrates excellent rapport with patient and family members :
Comments :
Provides services as instructed in the Plan of Care :
Comments :
Demonstrates knowledge of infection control such as Standard/Universal Precautions :
Comments :
Demonstrates competency in providing care :
Comments :
Documentation is clear timely and accurate :
Comments :
Wearing agency photo ID :
Comments :

Assessment History Schedule Discharge

Sl.no Assessment type Date Actions
assessment_type == 'initial_assessment') { ?> Initial Assessment Report report_entry_date;?>