Daily Census Changes Add or subtract from the beginning census each event during the designated census period Method a Shift 1 or Method b patient day 8 hours after beginning of Beginning Census Admissions Discharges Transfers Deaths Other Total Direct Care of Census Period Total CNA Direct at End of Census Period CDPH 612 6/18 11. State of California-Health and Human Services California Department of Public Health Census and Direct Care Service Hours Per Patient Day DHPPD 1. Patient Date MM/DD/YY 2. Patient Date Start Time HH MM AM/PM 3. Total Licensed Skilled Nursing Beds 4. CDPH License 5. Facility Name 6. Facility Address 7. Administrator 8. Director of Nursing/Designee 9. Estimated Direct Care Service Hours and DHPPD Beginning Patient Census Scheduled Total Direct Care Service Hours Scheduled DHPPD 10. Actual Direct Care Service Hours and DHPPD This section must be completed at the end of each 24 hour patient day. Average Actual/Final Total Direct Total CNA Care Service Hours CNA ....
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How to fill out the CA CDPH 612 online
The CA CDPH 612 form is essential for documenting the census and direct care service hours per patient day in skilled nursing facilities. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.
Follow the steps to successfully complete the CA CDPH 612 online.
- Use the ‘Get Form’ button to access the CA CDPH 612 online form and open it.
- Enter the patient date in the format MM/DD/YY.
- Input the total number of licensed skilled nursing beds for your facility.
- Fill in the patient date start time using the format HH:MM AM/PM.
- Enter the facility's CDPH license number.
- Provide the facility name.
- For scheduled total direct care service hours, input the total hours scheduled for the patient day. Record the beginning patient census at midnight, and the scheduled DHPPD will be calculated automatically.
- Input the scheduled total CNA direct care service hours, which will also auto-calculate the scheduled CNA DHPPD.
- Record daily census changes at 12:00 AM, 8:00 AM, and 4:00 PM, tracking admissions, discharges, transfers, and deaths. The ending census auto-populates as the beginning census for the next period.
- At the end of the patient day, enter the actual total direct care service hours and actual total CNA direct care service hours.
- The average patient census and actual DHPPD will be auto-calculated based on the information provided.
- Finally, the Director of Nursing or their designee should review the information for accuracy and sign the form to verify that it is complete.
Complete your CA CDPH 612 form online today for accurate reporting.
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