Care Plans

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CMS-485 Plans of Care

Patient	Episode #	Cert Period	Status	Physician	Disciplines	Sent Date	Signed Date	Actions
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1. Patient Information & Certification Period

Patient Name

Date of Birth

Medical Record #

Medicare #

Cert Period Start

Cert Period End

Cert Period #

Attending Physician

2. Diagnoses

Primary Dx Code

Primary Dx Description

Secondary Dx 1 Code

Secondary Dx 1 Description

Secondary Dx 2 Code

Secondary Dx 2 Description

Secondary Dx 3 Code

Secondary Dx 3 Description

3. DME and Supplies

4. Safety Measures, Nutritional Requirements & Allergies

Safety Measures

Nutritional Requirements

Allergies

7. Mental Status

Oriented

Confused

Forgetful

Depressed

Disoriented

Lethargic

Agitated

Other

8. Orders for Discipline and Treatments

Discipline	Order Description	Frequency	Total Visits	Actions
No orders added yet. Click "Add Order" to begin.

9. Goals

Discipline	Goal Description	Target Date	Status	Actions
No goals added yet. Click "Add Goal" to begin.

10. Physician Certification & Signature

Physician Name

Signature Status

Not Sent

Sent Date

Signed Date

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CMS-485 Plans of Care