Get Hospital Bed Evaluation Form

This guide will assist you in completing the Hospital Bed Evaluation Form online with confidence. Follow the clear steps outlined below to ensure that all required information is accurately provided.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Begin with Section I: General Information. Enter the date of evaluation, recipient's name, date of birth, address, height, weight, Medicaid ID number, and any other insurance information. Ensure that the provider initials this section.
3. Proceed to Section II: Medical History. Fill in the diagnosis, age at diagnosis, prognosis, summary of medical condition warranting a pediatric hospital bed, and estimated length of need. This section must also be initialed by the provider.
4. In Section III: Present Pediatric Hospital Bed, indicate whether the recipient currently owns a hospital bed. If yes, provide the required details including serial number, age, model, size, price, and funding source. Note why the current bed does not meet the recipient's needs and if it can be repaired.
5. Section IV: Home Environment necessitates selecting the type of residence and availability of caregivers. Assess if the home can accommodate a pediatric hospital bed and whether modifications will be made.
6. For Section V: Cognition, you'll assess the recipient's memory, problem-solving ability, attention, vision, hearing, and judgment—recording any impairments with comments.
7. Continue to Section VI: Communication. Include the recipient's mode of communication, such as verbal or sign language.
8. In Section VII: Sensation, assess and note any impairments, history of pressure sores, and bowel or bladder management status.
9. For Section VIII: Pathological Reflexes, identify and describe any relevant reflexes observed during the assessment.
10. Section IX: Mobility focuses on the recipient's bed mobility and transfer capabilities. Indicate their level of independence and any mobility devices used.
11. In Section X: Pediatric Hospital Bed Trial & Considerations, provide information on the recipient's seizures, need for medical positioning, and any safety issues with ordinary beds.
12. Section XI to XIV involves additional assessments such as posture, upper and lower extremity evaluations, balance, pain, and edema observations.
13. Complete Section XVII, detailing the recommended pediatric hospital bed and any non-standard parts required. Ensure justification is provided for each recommendation.
14. Finally, gather required signatures from the therapist and physician, ensuring full completion of the form, before saving changes, downloading, printing, or sharing the filled document.

Complete the Hospital Bed Evaluation Form online today for timely assistance.