INTRODUCTION
This article is an overview of templates and how they are intended to be used in the system.
See below for Tips, Terms, and Related Articles
BENEFITS
- Minimizes the chance of a document getting rejected by the Signer’s office
- Ensures accuracy
Templates define:
1. Signature Location, and
2. Document Type
Effective Date is the date that the document became effective. Examples include: ● Date a verbal order was given,
● Start of Care for a “home health certification”, or initial plan of care,
● Start of Episode for a “recertification”.
○ (NOTE: if Start of Care ≠ Start of Episode, the document is a recertification, NOT a certification.)
Template Types & Descriptions
NAME | ALSO KNOWN AS | DESCRIPTION |
COMMONLY MISTAKEN | ||
Home Health Certification | 485, Cert, Plan of Care (POC), Plan of Treatment (POT) | Initial certification for home health services that includes the initial plan of care. Start of Care = Start of Episode |
Home Health Eligibility Summary | Information provided by agency to document a patient’s eligibility for home health services, often used as corroborating information for the Face-to-Face | |
Home Health Face-to-Face Note | F2F note | Home Health Face-to-Face encounter note from a different physician sent to new physician for signature |
Home Health Recertification | 485, Recert, Plan of Care (POC), Plan of Treatment (POT) | Re-certification (subsequent certification) for home health services that includes the subsequent plan of care. Start of Care ≠ Start of Episode |
Plan of Care Approval (Home Health) | PCP approval of a plan of care provided by a different physician OR an order that includes an estimated duration of need for home health services.
This is NOT a Certification. | |
GENERAL | ||
Discharge Summary - Hospital | DC Summary | Discharge summary from hospital |
General Communication | Miscellaneous communication |
Medical Order | Miscellaneous medical order | |
Medication Summary | Summary of medications | |
Wound Photo | Photo of wound | |
HOME HEALTH | ||
Discharge Summary - Home Health | DC Summary | Summary of patient’s care throughout episode provided at time of discharge |
Home Health Assessment | Assessment, OASIS | In whole or in part, an assessment of patient, such as OASIS, sometimes used as corroborating information for the Face-to-Face encounter |
Home Health Certification | 485, Cert, Plan of Care (POC), Plan of Treatment (POT) | Initial certification for home health services that includes the initial plan of care. Start of Care = Start of Episode |
Home Health Eligibility Summary | Information provided by agency to document a patient’s eligibility for home health services, often used as corroborating information for the Face-to-Face | |
Home Health Face-to-Face | F2F, Face-to-Face
Encounter | Documentation of face-to-face encounter with physician as required for initiation of home health services |
Home Health Face-to-Face
(non-primary) | F2F, Face-to-Face
Encounter | Same as Home Health Face-to-Face with initial orders included, typically because physician completing will not be signing the Certification. |
Home Health Face-to-Face Note | Home Health Face-to-Face encounter note from a different physician sent to new physician for signature | |
Home Health Interim Order | Physician Order (PO), Physician Interim Order (PIO), Supplemental
Order, Verbal Order | General-use order after the initial plan of care. similar to Medical Order but specific to home health. |
Home Health Recertification | 485, Recert, Plan of Care (POC), Plan of Treatment (POT) | Re-certification (subsequent certification) for home health services that includes the subsequent plan of care. Start of Care ≠ Start of Episode |
Plan of Care Approval | PCP approval of a plan of care provided by a different physician OR an order that includes an estimated duration of need for home health services.
This is NOT a Certification. | |
Statement of Medical Need | Document stating why patient needs home health services required by some states (i.e. TX) | |
HOSPICE | ||
Certificate of Terminal Illness | CTI | Physician certification that patient has a terminal illness as required for the hospice benefit. |
Discharge Summary - Hospice | DC Summary | Summary of patient’s care throughout episode provided at time of discharge |
Hospice Certification | Cert, Plan of Care (POC), Plan of Treatment (POT) | Initial certification for hospice services that includes the initial plan of treatment. |
Hospice Interim Order | Physician Order (PO), Physician Interim Order (PIO), Supplemental
Order, Verbal Order | General-use order after the initial plan of treatment. similar to Medical Order but specific to hospice. |
Hospice Recertification | Recert, Plan of Care
(POC), Plan of Treatment (POT) | Subsequent certification for hospice services that includes the subsequent plan of treatment. |
MEDICAL SUPPLY | ||
Certificate of Medical Necessity | CMN | Certification by a physician that a patient needs a particular medical device. |
Medical Supply Order | Medical order for a medical device. | |
NUTRITION | ||
Nutrition Order | General-use order after the initial plan of care. similar to Medical Order but specific to nutrition. | |
OCCUPATIONAL THERAPY | ||
Discharge Summary - Occupational Therapy | DC Summary | Summary of patient’s care throughout episode provided at time of discharge |
Occupational Therapy Certification | Cert, Plan of Care (POC), Plan of Treatment (POT) | Initial certification for OT services that includes the initial plan of treatment. |
Occupational Therapy Evaluation | Eval | Initial evaluation of patient for OT services |
Occupational Therapy Order | General-use order after the initial plan of care. similar to Medical Order but specific to OT. | |
Occupational Therapy
Recertification | Cert, Plan of Care (POC), Plan of Treatment (POT) | Subsequent certification for OT services that includes the subsequent plan of treatment. |
PHARMACY | ||
Pharmacy Order | General-use order after the initial plan of care. similar to Medical Order but specific to pharmacy. | |
PHYSICAL THERAPY | ||
Discharge Summary - Physical Therapy | DC Summary | Summary of patient’s care throughout episode provided at time of discharge |
Physical Therapy Certification | Cert, Plan of Care (POC), Plan of Treatment (POT) | Initial certification for PT services that includes the initial plan of treatment. |
Physical Therapy Evaluation | Eval | Initial evaluation of patient for PT services |
Physical Therapy Order | General-use order after the initial plan of care. similar to Medical Order but specific to PT. | |
Physical Therapy Recertification | Cert, Plan of Care (POC), Plan of Treatment (POT) | Subsequent certification for PT services that includes the subsequent plan of treatment. |
SPEECH THERAPY
Discharge Summary - Speech Therapy | DC Summary | Summary of patient’s care throughout episode provided at time of discharge |
Speech Therapy Certification | Cert, Plan of Care (POC), Plan of Treatment (POT) | Initial certification for ST services that includes the initial plan of treatment. |
Speech Therapy Evaluation | Eval | Initial evaluation of patient for ST services |
Speech Therapy Order | General-use order after the initial plan of care. similar to Medical Order but specific to ST. | |
Speech Therapy Recertification | Cert, Plan of Care (POC), Plan of Treatment (POT) | Subsequent certification for ST services that includes the subsequent plan of treatment. |
Tips
- It is extremely important to SELECT THE CORRECT TEMPLATE in SutureHealth so that the document is processed correctly.
TERMS USED IN THIS ARTICLE
Template:
Tells SutureHealth and the Signer’s team what type of document is being sent.
