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Minnesota Department
of Health
Case Mix Review
Facility and Provider Compliance Division
85 East Seventh Place, Suite 300
P.O. Box 64900
St. Paul, MN 55101
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Attachment IV
MEDICAL PLAN OF CARENOTE: An Interagency Transfer
For, History and Physical,
or a Hospital Discharge Summary may
be submitted in lieu of this form.
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| Facility Name: |
Location Number: |
City: |
| Resident's Name: |
CMR Case #: |
PMI #: |
| Date of
Admission/Re-admission: |
| Physician's Name: |
| Primary Diagnosis: |
Secondary Diagnoses:
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Medications: Dose:
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Treatments:
Frequency:
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What Clinical
Monitoring is Needed?
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What Rehabilitation
Procedures are Needed?
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| Rehabilitation
Potential: |
| Discharge Potential: |
Other Comments:
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Signature___________________________________M.D.
Date_________________
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Updated Tuesday, 16-Nov-2010 08:51:37 CST
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