• Name:
    first_name.' '.$datas->last_name?>
  • Birth:
    dob?>
  • Email:
    patient_email?>
  • Gender : gender?>
  • Merital : marital_stat?>
  • Weight : weight?>
  • Direction : direction?>
  • #Soc Sec No : soc_sec_no?>
  • Address:
    address?>
  • Height : height?>

Patients Info

  • Level of Care : level_of_care?>
  • Designate First Name designate_first_name?>
  • EVV Verification evv_verification?>
  • Coardinator coordinator?>
  • Primary Nurse primary_nurse?>
  • Designate Last Name designate_last_name?>
  • Designate Telephone designate_telephone?>
  • Designate Cell designate_last_name?>
  • Intake Nurse intake_nurse?>
  • Referal Source referral_source?>

Care Info

  • Level of Service Needlevel_service?>
  • New Ordernew_order?>
  • Service Activity Neededservice_activity?>
  • Therapy Typetherapy_type?>
  • Type Of Accesstype_access?>
  • Patient Seen By Mdpatient_seen_by_MD?>
  • Current Lab Workcurrent_lab_work?>
  • Lab Orderlab_order ?>
  • Additional Lab Orderother_lab_frequency?>
  • Lab Frequencylab_frequency?>
  • Other Lab Frequencyother_lab_frequency?>
  • Tubetube_type?>
  • Formulaformula?>
  • Scheduleschedule?>
  • Flush Withflush_with?>
  • Daily Intake Requirmentdaily_intake_requirment?>
  • Flush Frequencyflush_frequency?>
  • Flush Restrictionsreferral_source?>
  • Flush Restriction Amountfluide_restric_amount?>

Patients Insurance Info

  • Insurance Type : insurance_type?>
  • Insurance Plan : insurance_plan?>
    • insurance_type == 'Madicaid') { ?>
  • Medicaid Id : medicaid_id?>
  • Medicaid Pedriatic : medicaid_pedriatic?>
  • Medicaid Adult : medicaid_adult?>
  • Type : primaryOrSecondary?>
  • Policy NO : Pvt_Ins_PlanId_Policy_no?>
  • Claim No : claim_no?>
  • Emergency contact
  • Name emgContactName?>
  • Relationship to the Pathient emgContactRelation?>
  • Address emgContactAddress?>
  • Telephone emgContactTelephone?>
  • Cell phone number emgContactCellNo?>
  • Other Number emgContactOteNo?>
  • Email emgContactEmail?>
  • Lives with Patient emgContactLiveswithPatient?>
  • Home access emgContactAccessToHome?>
  • Emergency Preparedness
  • Evacutaion zone EmgPrepdEvacZone?>
  • Mobility Status EmgPrepdMobilityStat?>
  • Evacuation Location EmgPrepdLocation?>
  • Electrical Equipment Dependency EmgPrepdEleDependency?>
  • Diaganosis
  • ICD diagonosisICD?>
  • Date diagonosisHistoricalDate?>
  • Historical data Diaganosis diagonosisData?>
  • Type diagonosisPrimary?>
  • Clinical Information
  • Start Of Care ClinicalStartOfCare?>
  • Allergies ClinicalAllergies?>
  • Allergic Reaction ClinicalAllergiesReaction?>
  • Notes ClinicalNotes?>
  • Physican and MD information
  • Name PhysicanName?>
  • Address PhysicanAddress?>
  • Telephone PhysicanTelephone?>
  • Email PhysicanEmail?>
  • Affiliation PhysicanAffiliation?>
  • FAX PhysicanFax?>
  • NPI PhysicanNPI?>
  • Lisence PhysicanLisence?>
  • Note PhysicanNote?>

Assessment History

Assessment type Date Day Actions
Initial Assessment date; ?> day; ?>