Medicare Evaluation Tool | Stroke or Coma Stroke or Coma Stroke or Coma - MED EVAL TOOLS Physician Name*Phone Number*Patient Name*Patient InformationMedicare requires documentation of need for hospice through prognostic data. Please supply that below:Please confirm patient dx:*StrokeMedicare requires documentation of need for hospice through prognostic data. Please supply that below:Inability to maintain hydration and caloric intake with one of the following:*Check all that apply: Weight loss > 10% in last 6 months or > 7.5% in the last 3 months Sequential calorie counts documenting inadequate caloric/fluid intake Serum albumin < 2.5 gm/dl Current history of pulmonary aspiration no response to speech language pathology intervention Dysphagia severe enough to prevent patient from continuing fluids/foods necessary to sustain life and patient does not receive artificial nutrition or hydration None of the above Other*Please specify (or mark field N/A):For non-traumatic hemorrhagic stroke:*Check all that apply: Large-volume hemorrhage on CT (Infratentorial: >/= 20 ml; supratentorial >/= 50 ml Midline shift >/= to 1.5 cm Ventricular extension of hemorrhage Surface area of involvement of hemorrhage >/= 30% cerebrum Obstructive hydrocephalus in patient who declines or is not a candidate for ventriculoperitoneal shunt None of the above Other*Please specify (or mark field N/A):For thrombotic/embolic stroke*Check all that apply: Large anterior infarcts with both cortical & subcortical involvement Bilateral vertebral artery occlusion Large bihemispheric infarcts Basilar artery occlusion None of the above Other*Please specify (or mark field N/A):ComaMedicare requires documentation of need for hospice through prognostic data. Please supply that below:Check all that apply Abnormal brain stem response Absent withdrawal response to pain Absent verbal response Serum creatinine> 1.5 mg/dl None of the above Other*Please specify (or mark field N/A):Supporting data: Incidence of any of the following within the previous 12 months:* Aspiration pneumonia Fever recurrent after antibiotics Pyelonephritis Refractory stage 3-4 decubitus ulcers None of the above Other*Please specify (or mark field N/A):Please respond YES or NO to the statements in this section:I support hospice care for this patient.*YesNoI will be patient’s attending physician.*YesNoI have discussed hospice with patient/loved ones.*YesNoI have discussed terminal diagnosis when it becomes necessary.*YesNoI will sign death certificate when it becomes necessary.*YesNo Based on the information indicated above, the above named patient has a medical prognosis that life expectancy is six (6) months or less, if the terminal illness runs its normal course. Digital Signature*Please enter your name below to serve as your electronic signature.VerificationEmailThis field is for validation purposes and should be left unchanged. Share this:TweetLike this:Like Loading...