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PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES(X1) PROVIDER/SUPPLIER/LIGAND PLAN OF CORRECTIONIDENTIFICATION NUMBER:15201407/20/2015FORM
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01
Open the visit form.
02
Fill in the patient's personal information (name, age, gender, contact details).
03
Provide relevant medical history or previous visit details.
04
Specify the chief complaint or reason for the visit.
05
Detail the symptoms or medical issues experienced by the patient.
06
Include any relevant medical test results or diagnostic reports.
07
List any prescribed medications or treatments.
08
Provide instructions or recommendations for follow-up care.
09
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10
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What is this visit was for?
This visit was for a routine inspection of the facility.
Who is required to file this visit was for?
The manager of the facility is required to file this visit.
How to fill out this visit was for?
The visit should be filled out by documenting the observations and findings during the inspection.
What is the purpose of this visit was for?
The purpose of this visit is to ensure that the facility is in compliance with regulations and standards.
What information must be reported on this visit was for?
The information reported should include any violations, corrective actions taken, and recommendations for improvement.
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