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Get 612 Form 2019-2024

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 DHPPD I have reviewed the patient census and direct care service hours information and acknowledge the information is true and correct. X Instructions The information on this form must be legible accurate and complete. All patients receiving nursing services and who are present in the facility during the patient day will be counted in the patient census. Only direct caregivers with a nursing services assignment shall be included in the DHPPD. To verify this form is complete true and accurate the Director of Nursing or his/her designee must sign this form* Do not include patient names. For a definition of DHPPD census direct caregiver direct care service hours or nursing services please see All Facilities Letter 18-27. 1. Enter the date of the patient day in MM/DD/YY format. 2. Enter the start time of the patient day in HH MM AM/PM format. Patient day must be prospective do not state that the patient day began on 11pm the previous day. 3. Enter the total number of licensed skilled nursing beds for the facility. 4. Enter the CDPH license number for the facility. 5. Enter the facility name. 7. Enter the name of the facility administrator. 9. Enter the census of the beginning of the patient day. Enter the total number of scheduled direct care service hours for the patient day. Divide the total number of scheduled direct care service hours by the beginning census. Enter this number as the scheduled DHPPD. 10. If using method a at the beginning of SHIFT 1 SHIFT 2 and SHIFT 3 enter the beginning census. If using method b at the beginning of the 24 hour patient day and at 8 and 16 hours after the beginning of the patient day enter the beginning census. For both methods throughout each shift record admissions discharges transfers deaths or other changes in census. Enter the direct caregivers total direct care service hours for each shift. In the last row enter the direct caregivers total direct care service hours at the end of each census period. 11. At the conclusion of the patient day record the average census experienced during the patient day by adding the three censuses and dividing by three.

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