Operational Checklists
Five role-specific checklists designed to be printed and used at the point of care. Each form includes checkbox fields for in-person completion, write-in lines for patient-specific data, regulatory citations, and a sign-off section.
Available Checklists
Referral Intake Checklist
Eligibility screening steps, clinical records collection, triage classification (eligible / MA / insufficient info / not eligible), and pre-evaluation handoff tasks. Use this before dispatching a nurse.
- Medicare Part A eligibility confirmation
- MA vs. fee-for-service triage
- Clinical records checklist
- 4-way triage classification
Admission Day Checklist
Pre-visit prep, patient rights delivery sequencing (before any clinical task), initial assessment content requirements, and post-visit documentation handoffs. The 48-hour clock and patient rights sequencing rule in a single checklist.
- 48-hour RN assessment deadline
- Patient rights sequencing (before clinical tasks)
- Initial assessment content domains
- IDG handoff and file checklist
Election Statement and NOE Checklist
All required election statement elements including the post-October 2020 additions, the addendum process, and the 5-day NOE deadline tracker with space to record submission and MAC acceptance dates.
- Election statement required elements
- Post-Oct 2020 required disclosures
- Addendum process steps
- 5-day NOE deadline tracker
Certification of Terminal Illness Checklist
Benefit period structure with correct signatory rules per period, required certification content, a narrative writing area, and the face-to-face attestation requirements (3rd+ periods) including the FY 2026 signature date requirement.
- Correct signatory per benefit period
- Patient-specific narrative area
- F2F attestation requirements (3rd+ periods)
- FY 2026 signature date rule
IDG Comprehensive Assessment Checklist
All 7 required IDG assessment domains with discipline-specific checklists, clinician sign-off fields per domain, plan-of-care completion steps, and a full IDG discipline signature grid. Designed to be passed between team members.
- All 7 required domains with checkboxes
- Per-domain clinician sign-off
- N/A deferral documentation
- IDG discipline signature grid
How to use these checklists. Open a checklist and use your browser's print function, or click the "Print This Checklist" button on the page. Forms are formatted for US Letter paper at 0.6-inch margins. Regulatory citations are included on each item for reference, not as legal guidance.