RN PATIENT VISIT – DATA CAPTURE FORMRN PATIENT VISIT — DATA CAPTURE FORM - rev. 2026.07 Patient Name (Last, First) * Patient ID / PAN # * Visit Date * Visit Type Time In * 121234567891011 : 000510152025303540455055 AMPMTime Out * 121234567891011 : 000510152025303540455055 AMPM Clinician Name * Clinician Discipline RN PT OT SLP Episode Timing OASIS Reason (M0100) Patient Date of Birth (until Race (A1010) are all patient demographics) * Gender/Sex * Male Female Other Medicare # Medicaid # SSN (last 4) * State of Residence * Zip Code * Preferred Language Interpreter Needed? Ethnicity (A1005) Not Hispanic/Latino Mexican/Chicano Puerto Rican Cuban Other Hispanic Declines UnableRace (A1010) White Black/African Am. Indian/Alaska Asian Native Hawaiian Other Pacific Other Declines UnableINSURANCE / PAYMENT SOURCES (M0150 — check all that apply) * Medicare FFS Medicare HMO Medicaid FFS Medicaid HMO Workers Comp Title Program Other Gov't Private Ins. Private HMO Self-Pay Other UnknownInpatient Discharge Past 14 Days (M1000) * Long-term NF SNF/TCU Acute Hospital LTCH Inpatient Rehab Psych Hospital Other NA — No inpatient stay Discharge Date (most recent) Occurrence Code ADVANCE DIRECTIVES - Living Will * Yes NoDNR? * Yes - Type:Yes - Type: No Patient Representative Name * DPOA? * Yes No Prior Medical History * Current Medical History * Patient Refuses Advance Directives? * Yes No Drug Allergies Patient Educated on Advance Directives? * Yes No Food Allergies DIAGNOSES (M1021 / M1023) * PrimaryPrimary Secondary 1Secondary 1 Secondary 2Secondary 2 Secondary 3Secondary 3 Secondary 4Secondary 4 Secondary 5Secondary 5Enter ICD-10 code, Description, Date, Severity (0–4).COMORBIDITIES & RISK - Active Comorbidities (M1028) * PVD / PAD Diabetes Mellitus None of the aboveHospitalization Risk Factors (M1033 — check all that apply) * Falls (2+ in 12mo) Wt loss >10lbs 2+ hospitalizations 2+ ED visits Mental decline Non-compliance w/ meds 5+ medications Exhaustion Other risksOther risks None of the above Other Risk Details / Recent Hospitalizations IMMUNIZATIONS - Influenza Yes. Indicate date given:Yes. Indicate date given: No NeedsIMMUNIZATIONS - Pneumonia Yes. Indicate date given:Yes. Indicate date given: No NeedsIMMUNIZATIONS - COVID-19 Yes. Indicate date given:Yes. Indicate date given: No NeedsIMMUNIZATIONS - Tetanus Yes. Indicate date given:Yes. Indicate date given: No NeedsIMMUNIZATIONS - Hepatits Yes. Indicate type and date:Yes. Indicate type and date: No Needs Patient's Stated Goals (in patient's own words) Patient-Identified Strengths & Weaknesses Patient Care Preferences If you are human, leave this field blank. Submit
