Get the free Fact Sheet: The Hospice Item Set (HIS) - CMS.gov
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OMB Control Number 09381153
Expiration 8/31/2021HIS Manual
Guidance Manual for Completion of
the Hospice Item Set (HIS)Centers for Medicare and Medicaid Services
Hospice Quality Reporting ProgramV2.01
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How to fill out fact sheet form hospice
How to fill out fact sheet form hospice
01
Start by gathering all the necessary information such as the patient's personal details, medical history, and current condition.
02
Begin filling out the fact sheet form by entering the patient's name, address, contact information, and date of birth.
03
Provide details about the patient's primary care physician and any other healthcare professionals involved in their care.
04
Document the patient's medical history, including any relevant diagnoses, ongoing treatments, or surgical procedures.
05
Specify the patient's current condition, noting any symptoms, pain levels, or changes in their health status.
06
Include information about the patient's medication regimen, including dosage, frequency, and any known allergies or adverse reactions.
07
Describe the patient's functional abilities and any assistance they require with daily activities.
08
Provide information about the patient's emotional and psychological well-being, including any signs of anxiety, depression, or distress.
09
Include details about the patient's support system, including family members, caregivers, or other individuals involved in their care.
10
Finally, review the completed fact sheet form for accuracy and completeness before submitting it to the hospice care provider.
Who needs fact sheet form hospice?
01
Individuals who require hospice care or are considering hospice services for themselves or their loved ones may need to fill out a fact sheet form hospice.
02
Healthcare professionals, such as physicians, nurses, or case managers, who are responsible for coordinating and providing hospice care may also need to complete fact sheet forms.
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What is fact sheet form hospice?
Fact sheet form hospice is a document that includes information about the services provided by a hospice facility.
Who is required to file fact sheet form hospice?
Hospice facilities are required to file fact sheet form hospice.
How to fill out fact sheet form hospice?
Fact sheet form hospice should be filled out with accurate information about the hospice services provided.
What is the purpose of fact sheet form hospice?
The purpose of fact sheet form hospice is to provide transparency and ensure hospice facilities are meeting regulatory requirements.
What information must be reported on fact sheet form hospice?
Information such as number of patients served, types of services offered, and staffing levels must be reported on fact sheet form hospice.
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