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Home Health Physician Order Form Template

Streamline Patient Care with Our Physician Order Form

Ensuring effective communication between healthcare providers and patients can be challenging, especially in home health contexts. This template is designed for home health agencies and physicians, helping you create precise physician orders that improve patient outcomes. Effortlessly manage patient needs, ensure compliance with care protocols, and facilitate seamless communication among care teams, all while simplifying documentation. Explore our live template to create your ideal physician order form.

Use this Template (FREE) Live Preview
Patient full name
Date of birth
Patient phone
Patient email
Home address (street, city, state, ZIP)
Emergency contact full name
Emergency contact phone
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Primary insurance payer
Member ID
Group number
Prior authorization number (if obtained)
Is prior authorization required?
Yes
No
Referring provider name
Referring provider NPI
Practice or facility name
Provider phone
Provider fax
Date of face-to-face encounter related to this home health need
Requested start of care date
Preferred home health agency (if any)
Is any qualified agency acceptable if preferred agency is unavailable?
Yes
No
Primary diagnosis (ICD-10 and description)
Secondary diagnoses and pertinent history
Is the patient homebound?
Yes
No
Reasons supporting homebound status
Please Specify:
Clinical findings relevant to home health needs
Infection control precautions required
Standard
Contact
Droplet
Airborne
None
Other
Please Specify:
Code status
Full code
Do not resuscitate (DNR)
Do not intubate (DNI)
Comfort focused
Unknown
List allergies and reactions
Known drug, latex, or food allergies?
Yes
No
Disciplines requested
Skilled nursing
Physical therapy
Occupational therapy
Speech-language pathology
Medical social worker
Home health aide
Wound care nurse
Infusion nurse
Other
Please Specify:
Visit frequency and duration (e.g., 3x/week x 4 weeks)
Specific skilled nursing orders and instructions (e.g., wound care, disease management, teaching, vitals parameters)
Therapy focus areas (if therapy ordered)
Please Specify:
Laboratory tests to be obtained in the home
Please Specify:
Lab details (timing, diagnosis code, special handling)
Current medications (name, dose, route, frequency)
Durable medical equipment and supplies requested
Please Specify:
Living situation
Alone
With family or caregiver
Assisted living
Skilled nursing facility
Other
Please Specify:
Primary language
Interpreter needed
Yes
No
Smoking status
Never
Former
Current
Prefer not to say
Ordering physician typed signature (full legal name)
Date signed
I certify that this patient is under my care, had a face-to-face encounter related to the need for home health services, is homebound, and requires skilled intermittent services as ordered.
Yes
No
{"name":"Patient full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Patient full name, Date of birth, Patient phone","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration depicting a home health physician order form template for FormCreatorAI article

When to use this form

Use this form whenever a physician must authorize skilled home care after a hospital stay, a new diagnosis, a change in condition, or a wound that needs ongoing treatment. It helps you translate a medical plan into clear, billable orders for nursing, therapy, labs, medications, and equipment. Clinicians get precise direction; patients get safer, coordinated care; and your agency reduces delays and denials. Pair it with a Home health assessment form to capture baseline needs and risks, then issue orders that match those findings. If a client is moving from a facility, align the orders with the Assisted living care plan form to keep care consistent during the transition. Typical uses include post-op joint replacement, heart failure monitoring, and complex wound management.

Must Ask Home Health Physician Order Questions

  1. What is the primary diagnosis and ICD-10 code for this episode?

    This focuses your plan of care and supports payer requirements. Clear coding helps your team prioritize interventions and shortens intake time.

  2. Which skilled services are ordered and what visit frequency is required?

    Listing disciplines and exact frequency prevents missed or unnecessary visits. It also guides scheduling and capacity planning.

  3. What treatments, medications, and wound care instructions should staff follow?

    Task-level instructions reduce errors and make visits actionable. They flow into ongoing documentation, including the Nursing visit report form, so you can track response to treatment.

  4. What is the start-of-care date, certification period, and face-to-face encounter date?

    These dates prove eligibility and keep you compliant with recertification timelines. They also help you coordinate start times across disciplines.

  5. What safety precautions, equipment, and caregiver instructions are required in the home?

    Noting risks and equipment reduces falls, infections, and readmissions. You can match orders to staff capabilities by confirming competencies with the Nursing skills checklist form.

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