Download - Noble House Direct

The
Comprehensive Remedysm
press the button next to the field.
Date Needed-Revised - If you indicated that this certificate was a revision or a re-certification, you must enter an
effective date of the revision or re-certification. This must be provided by the ordering physician. To quickly clear
this date, press the button next to the field.
Date Signed - The date on which the paper CMN was completed and signed by the ordering physician. To quickly
clear this date, press the button next to the field.
Question 12 - Is the patient highly susceptible to decubitus ulcers?
Question 13 - Are you supervising the use of the device?
Question 14 - Does the patient have coexisting pulmonary disease?
Question 15 - Has a conservative treatment program been tried without success?
Question 16 - Was a comprehensive assessment performed after failure of conservative treatment?
Question 19 - Are open, moist dressings used for the treatment of the patient?
Question 20 - Is there a trained fulltime caregiver to assist the patient and manage all aspects involved with the use
of the bed?
Question 21 - Provide the stage and size of each pressure area / ulcer necessitating the use of the overlay, mattress,
or bed.
Question 22 - If you have indicated ulcer(s) in the previous questions, you should answer the following question.
Over the past month, the patient's ulcer(s) has/have: "1" Improved, "2" Remained the Same, or "3" Worsened. Enter
the number of the appropriate response.
File Maintenance
4-13