Royal Home Health Care

Print form and Fax to 718-228-5386

E-mail: Intake@rchomecare.com

From:
Facility:
Phone #:
Fax #:
Email:

PHYSICIAN SIGNING HOME CARE ORDERS

PHYSICIAN NAME:

ADDRESS:

PHONE #:		FAX #:
NPI #:		LICENSE #:

Reason for Home Care

DIAGNOSIS (Indicate * if a new diagnosis):

ALLERGIES:

MEDICATIONS / DOSE / FREQUENCY/ ROUTE::

DIABETES: TYPE 1 TYPE 2 GESTATIONAL
Teach diabetic manager / self care
Teach glucose monitoring
Contact MD If blood glucose is above or below
Diet

CARDIOVASCULAR DISORDERS:
Educate on signs and symptoms of: CHF,Ml,CAD,A.Fib,HTN
Assess cardiac status Daily weight recording
Current weight
Contact MD for BP

systolic above or below
diastolic above or below

Apical pulse above or below
Diet

Attach Face Sheet(s) / Clinical Info

DOCTORS TREATMENT / ORDERS:

MD Signature Date

PATIENT INFORMATION

LAST NAME:
FIRST NAME:
SEX Phone #:
ADDRESS Apt #
CITY STATE NY ZIP #
DATE OF BIRTH SSN #
LIVES WITH
ETHNICITY:
LANGUAGE SPOKEN BY PATIENT:
MENTAL HEALTH STATUS
Is the patient self-directing?
FAMILY CONTACT / RELATIONSHIP
CONTACT TELEPHONE # Day Evening
MEDICARE # MEDICAID #
COMMERCIAL INSURANCE CARRIER (NAME&AUTHORIZATION)

SUBSCRIBER
POLICY # GROUP #

Reason for Home Care Continued

WOUNDS:
2, 3 day supply given to patient
Pressure Venous Arterial
Diabetic Other
Location
Stage & size of wound

WOUND CARE:
Hydrogel Ca-Alginate Hydrocolloid NS wet to damp
OTHER

Frequency:

GAIT / AMBULATORY STATUS:
Did patient have a Rehab Hospital/Unit admission within the last 10 days?

SKILLED SERVICES:
Frequency: times per week for weeks
RN PT OT ST MSW HHA

LAB REQUEST:
Albumin SMAC CBCw/diff PT/INR HbA1c
Other:
Frequency:

MEDICATIONS / DIET CHANGES:
Teach medication and adherence with new/old regimens
Teach nutrition Diet:

ASTHMA / COPD: Assess home for triggers
Educate on disease management Peak Flow Meter
Educate on use of nebulizers/inhalers Educate O2 precautions