New Jersey Department of Health

Division of HIV, STD and TB Services

HIV Home Care Program

MONTHLY ACTIVITY REPORT	/
Client ID
Month/Year
Refer to the “Instructions for Completion of the Monthly Activity Report.”

Name of Agency

County

Name of Case Manager

Date

Enrollment Date	Date of Birth	Discharge Date
/	/
/	/
/	/
Reason for Discharge

Improved Health ACCAP Medicaid Nursing Facility Hospital Hospice
Expired - Date of Expiration:	/	/	Where did Client expire? Hospital Home
Other (specify):
Linkage with Long-Term Reimbursement Systems:

Application Date	Approval Date	Denial Date
SSI
SSD
ACCAP
Medicaid
Other (Specify):
Client Condition

Good Fair Poor Guarded Wasting Cognitive Impairment
Has client been hospitalized since last monthly report?

Yes No If Yes, provide hospital dates:	Admission Date	Discharge Date
/	/
/	/
Justify the utilization of home care services based upon client’s medical and nursing needs, such as wound care, new diagnoses and treatment modalities, ADL and IADL deficits, etc.

NursING Services	Date of Visit(s)	Payer	Drug Adherence

# Minutes
Skilled RN
Skilled RN
Skilled RN
Skilled RN
Skilled RN
Skilled RN
Skilled RN
Skilled RN for HHA/PCA Supervision
Skilled RN for Dedicated Drug Adherence
Skilled RN for IV Administration
Skilled RN for Respiratory Therapy
LPN
CASE MANAGEMENT	Date of Visit	Payer
Initial Visit
Monthly Visit

MONTHLY ACTIVITY REPORT

Continued	/
Client ID
Month/Year
PARAPROFESSIONAL SERVICES	Number of Hours	Payer
Homemaker/Home Health Aide
Personal Care Attendant
rehabilitation	Date of Visit(s)	Payer
Occupational Therapy
Physical Therapy
Speech Therapy
mental health	Date of Visit(s)	Payer
Counselor
Medical Social Worker
Psychiatric Nurse
nutritional counseling	Date of Visits	Payer
Registered Dietician
Registered Nurse
IV Therapy	Date of Treatment(s)	Payer
IV Medications
IV Equipment and Supplies
Respiratory CARE	Date of Treatment(s)	Payer
Respiratory Therapist
Aerosolized Medications
Cost Per Day:	$	X Number of Days	= Total Cost	$
diagnostic testing	Date	Payer
Diagnostic/Lab Tests
Diagnostic Equipment and Supplies
Skilled RN/Phlebotomist
durable medical equipment (DME), materials and supplies

Equipment Item(s)	Monthly Rental or Purchase Cost	Payer
nutritional supplements
Cost Per Can:	$	X No. of Cans	= Total Cost	$	Payer:
escort service	Date of Visit(s):	Payer:
MEDICAL DAY CARE	Number of Days:	Payer:
BILLING FEE:	$20.00	X Number of Service Categories:	= Total Cost	$
Comments:

Case Manager Supervisor Signature	Date

DHAS-20

JUL 12	Page 2 of 2 Pages.

JUL 12	Page 1 of 2 Pages.

DHAS-20 Monthly Activity Report

HIV, STD and TB Services, HIV Home Care Program, NJDOH, health

Elaine White

2002-02-28

ewhite

NJDOH