Transcription of COMPREHENSIVE PEDIATRIC NURSING ASSESSMENT
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Primary Diagnosis/Reason for Home CareICD Code(Locator #11)a. _____ ( _____ ) Date _____ O EOther Diagnosis/ReasonsICD Code(Locator #13)b. _____ ( _____ ) Date _____ O Ec. _____ ( _____ ) Date _____ O Ed. _____ ( _____ ) Date _____ O Ee. _____ ( _____ ) Date _____ O Ef. _____ ( _____ ) Date _____ O EHistory/Surgical ProcedureICD Code(Locator #12)_____ ( _____ ) Date _____ O E_____ ( _____ ) Date _____ O EPatient s HI Claim No.: (Locator #1) Same as Medicaid CHIP (Childrens Health Insurance Program) Self or family pays full or partial costs Other_____Gender: (Locator #9) 1-Male 2-FemaleEthnicity and Race: American Indian or Alaska Native Native Hawaiian or AsianPacific Islander Black or African-American White Hispanic or Latino OtherMedicaid Provider Number: (Locator #5) _____Patient ID / Medical Record Number: (Locator #4)_____ Start of Care Date: (Locator #2) _____month/day/yearCertification Period: (Locator #3) (if applicable)From _____ To _____Patient s Name: (Locator #6)_____ ____ (First)(MI)_____(Last)(Suffix)Patient Phone: _____ - _____ - _____Patient Address: (Locator #6)_____(Street/Apt.)
NURSING ASSESSMENT WITH PLAN OF TREATMENT/485 INFORMATION PATIENT NAME – Last, First, Middle Initial ID# COMPREHENSIVE PEDIATRIC NURSING ASSESSMENT Page 1 of 14 DATE OF SERVICE _____ TIME IN _____ OUT _____ ALLERGIES: (Locator #17) None known Aspirin Penicillin Sulfa Pollen
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