Minnesota Department of Health

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39.  LEVEL OF CARE                    - 39 - 40:  CMR teams see -
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                                      -           Pages I-VII   -
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40.  COMPONENT OF CARE           
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CURRENT/ACTIVE DIAGNOSES (Back of form)

Code the physician's current active medical diagnoses as
recorded in the medical record.

Code up to six diagnoses only.  

     If a primary diagnosis is not listed, enter it in
     the top left corner.  DO NOT CODE.
     Mark the bubble  in the comments box on the bottom
     front of the form.


SIGNATURES/DATE

Signature of the registered nurse performing the assessment.
     
Code date of assessment.

Include WORK PHONE NUMBER in R.N. signature box. 

          


          


                            DO NOT 
                FOLD, STAPLE, HOLE PUNCH OR TAPE
                       ASSESSMENT FORMS.

                                
                 USE ONLY PAPER CLIPS TO ATTACH
                   ACCOMPANYING DOCUMENTATION
                                

Updated Tuesday, 16-Nov-2010 08:51:37 CST