Policy Manual sample

MDT Home Health Care Agency, Inc. EMERGENT CARE FOR INJURY CAUSED BY FALL OR ACCIDENT AT HOME REVIEW TOOL Patient ID#: ______________ Age:____________ Sex: M F SOC Date: ______________ D/C Date: _______________ Primary Dx: ______________________________ Secondary Dx: ______________________ Fall? Yes No Accident? Yes No Time of Fall/Accident ______________ AM PM Criteria Yes No Comment 1. Live alone? 2. Caregiver? 3. Use Assistive Device? Which one? 4. Prior to fall/accident, was patient safety evaluation done? 5. If safety recommendations made, did patient implement them? 6. What services were in place before: Nursing PT OT HHA 7. Services after fall/accident: Nursing PT OT HHA 8. Documentation of fall/accident? 9. Prior did HHA see pt. within 72 hrs. 10. Was there an injury? What 11. ED Visit? 12. Physician notified? 13. Hospitalized? 14. Could fall have been prevented? 15.Were safety measures implemented after the fall/accident? Home Health Agency Nursing Care & Procedures K-127