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Medicare Evaluation Tool | Stroke or Coma

Stroke or Coma

Stroke or Coma - MED EVAL TOOLS

Physician Name*
Phone Number*
Patient Name*
Patient Information
Medicare requires documentation of need for hospice through prognostic data. Please supply that below:
Please confirm patient dx:*
Stroke
Medicare 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):
Coma
Medicare requires documentation of need for hospice through prognostic data. Please supply that below:
Check all that apply
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.*
- Yes
- No
I will be patient’s attending physician.*
- Yes
- No
I have discussed hospice with patient/loved ones.*
- Yes
- No
I have discussed terminal diagnosis when it becomes necessary.*
- Yes
- No
I will sign death certificate when it becomes necessary.*
- Yes
- No
- 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.
Verification
Comments
This field is for validation purposes and should be left unchanged.

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Serving Colusa, Sacramento, Solano, Sutter and Yolo Counties.

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YoloCares
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