Cdph 612 form 2026

1. Click ‘Get Form’ to open the cdph 612 form in the editor.
2. Begin by entering the patient date in MM/DD/YY format. This is crucial for accurate record-keeping.
3. Next, input the start time of the patient day using HH:MM AM/PM format. Ensure this reflects the prospective start time.
4. Fill in the total number of licensed skilled nursing beds available at your facility.
5. Enter your facility's CDPH license number, followed by the facility name and address.
6. Provide the names of both the administrator and the Director of Nursing or their designee responsible for that day.
7. Document the beginning patient census and scheduled direct care service hours, then calculate and enter the scheduled DHPPD.
8. For daily census changes, record any admissions, discharges, transfers, or deaths during each shift as per your chosen method.
9. At day's end, calculate and enter actual total direct care service hours and final DHPPD based on average census data.
10. Finally, ensure that the Director of Nursing or designee reviews and signs off on the form to verify its accuracy.

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