Patient Name: Patient ID: Visit Date: Episode Date: SN Visit Note Vital Signs Not ed Temperature: Pulse Apical: Reg Irreg Resp: / min Pulse Radial: Reg Irreg B/P (L) B/P (R) Sitting: / Sitting: / Standing: / Standing: / Lying: / Lying: / Lung Sounds (L): Lung Sounds (R): Pulse Ox: Patient unable to stand PT INR: Weight: Body Circumference Arm: Left Lbs Kg Height: Right Feet Inches Body Circumference Thigh: Telehealth Monitoring Blood Sugar Not ed Blood Glucose Check Performed: Result: mg/dl Hours: FSBS: Range Oxygen Not ed Oxygen by L/Min for shortness of breath. Allergies Pain ment Location: No Pain Reported Pain Type: Aching Constant Annoying Stabbing Dull Aching Nagging Throbbing Prickling Burning Gnawing Shooting Electric Pain Type : 1
Non-Verbal Pain ment Non Reported/Observed Restlessness Rigidity Crying Facial Grimaces Guarding Moaning Other Onset: What makes pain worse? What makes the pain better? History of pain management: Current Pain Control Regimen / Effectiveness of pain control regimen: Repositioning Rest / Relaxation Heat Massage Ice Diversion Medication Other Pain Control Regimen : Relief with Medications: Patient s acceptable level of pain: 0 1 2 3 4 5 6 7 8 9 10 Patient s present level of pain: 0 1 2 3 4 5 6 7 8 9 10 Care plan reflects pain intervention / goals Routine ed / No Problem Understanding of medication purpose, dosage, and side effects: Effectiveness of telehealth program to prevent unnecessary rehospitalizations: Signs / symptoms of disease exacerbation: 2
Medication Back : Disease Management Back : Patient / caregiver verbalizes understanding of the following: Cardiac ed / No Problem Shortness of breath: Dyspnea on exertion: Chest pain: Endurance level: Patient / caregiver understanding of medication purpose, dosage, and side effects: Understanding importance of rest periods: Understanding of prescribed diet: Effectiveness of telehealth program to prevent unnecessary rehospitalizations: Signs / symptoms of cardiac disease: Energy conservation principles: Importance of adherence to medication protocol: Medication Back : 3
Disease Management Back : Patient / caregiver verbalizes understanding of the following: Cardiac Surgery ed / No Problem Shortness of breath: Dyspnea on exertion: Chest pain: Surgical wound site: Post-op endurance level: Understanding of prescribed diet: Patient / caregiver understanding of medication purpose, dosage, and side effects: Understanding importance of rest periods: Effectiveness of telehealth program to prevent unnecessary hospitalizations: Signs / symptoms of cardiac disease: Energy conservation principles: Signs / symptoms surgical wound site infection: Importance of compliance with prescribed diet: Importance of adherence to medication protocol: Medication Back Disease Management Back Importance of discharge planning in maintaining long term cardiac health: 4
Patient / caregiver verbalizes understanding of the following: Remove staples: Diabetes ed / No Problem Ability to perform insulin administration: Ability to perform blood glucose testing: Signs / symptoms hyper/hypoglycemia: Understanding of diabetic diet: Diabetic foot care: Understanding of sick day management: Patient / caregiver understanding of medication purpose, dosage, and side effects: Patient / caregiver understanding of Disease Management principles: Insulin administration: Blood glucose testing: Signs / symptoms of hyper/hypoglycemia: Importance of diabetic diet to maintain healthy blood glucose: Principles of diabetic foot care: Sick day management: Importance of strict adherence to medication protocol: Medication Back : Disease Management Back : Importance of discharge planning in maintaining long term health: 5
Patient / caregiver verbalizes understanding of the following: Signs / symptoms of hyper/hypoglycemia: Administration of insulin: Blood glucose monitoring: Diabetic diet: Diabetic foot care: Insulin administration: Medication prefill: Blood glucose testing: Diabetic foot care: Heart Failure ed / No Problem Shortness of breath: Dyspnea on exertion: Pedal edema: Understanding of low sodium diet: Understanding of oxygen therapy & safety: Understanding of medication purpose, dosage, and side effects: Need for PRN dose of diuretic: Understanding importance of rest periods: Effectiveness of telehealth program to prevent unnecessary rehospitalizations: Signs / symptoms of heart failure: Importance of low sodium diet to maintain healthy breathing / endurance: Importance of PRN dose of diuretic when indicated: Energy conservation principles: 6
Importance of prescribed oxygen therapy to prevent heart failure symptoms: Importance of adherence to medication protocol: Medication Back : Importance of discharge planning in maintaining long term cardiac health: Patient / caregiver verbalizes understanding of the following: Low sodium diet: Oxygen therapy usage and purpose: IV Lasix Push: IV ed / No Problem IV Site: Type of VAD: IV site for signs / symptoms infection: Patient / caregiver understanding of IV administration: Patient / caregiver understanding of medication purpose, dosage, and side effects Understanding of prescribed diet: 7
Signs / symptoms of VAD site infection: IV administration: VAD dressing change: VAD flushes: Importance of adherence to medication protocol: Medication Back : Disease Management Back : Importance of discharge planning: Patient / caregiver verbalizes understanding of the following: Signs & symptoms of VAD site infection: IV medication administration: TPN administration: VAD dressing change: VAD flushes: Lab work: Access Porta/cath with Huber needle: Patient / caregiver demonstrates VAD flush: Patient / caregiver demonstrates IV administration: Patient / caregiver demonstrates VAD dressing change: Neurological ed / No Problem Syncope: Vertigo: Hand grips: Seizures: 8
PERL: Tremors: Balance: Speech: Paralysis: Mental Status: ADL ability: Understanding of prescribed diet: Patient / caregiver understanding of medication purpose, dosage, and side effects: Effectiveness of telehealth program to prevent unnecessary rehospitalizations: Home / personal safety: Safe ambulation: Safe transfers: Seizure precautions: Importance of adherence to medication protocol: Medication Back : Disease Management Back : Importance of discharge planning in maintaining long term safety: Patient / caregiver verbalizes understanding of the following: Home safety: Respiratory ed / No Problem 9
Shortness of breath: Dyspnea on exertion: Cough: Cyanosis Endurance: Compliance with oxygen therapy & safety: Effectiveness of oxygen therapy: Compliance with nebulizer: Patient / caregiver understanding of medication purpose, dosage, and side effects: Effectiveness of telehealth program to prevent unnecessary rehospitalizations: Signs / symptoms of respiratory infection: Importance of low sodium diet to maintain healthy breathing / endurance: Energy conservation principles: Importance of prescribed oxygen therapy to prevent respiratory distress: Importance of using nebulizer as directed: Medication Back : Disease Management Back : Importance of discharge planning in maintaining long term cardiac health: Patient / caregiver verbalizes understanding of the following: Oxygen therapy usage and purpose: 10
Symptom Management ed / No Problem Nausea / vomiting: Diarrhea: Shortness of breath: Dyspnea on exertion: Mouth sores: Fluid Intake: Nutritional intake: Skin integrity: Compliance with oxygen therapy & safety: Effectiveness of oxygen therapy: Patient / caregiver understanding of medication purpose, dosage, and side effects: Understanding importance of rest periods: Effectiveness of telehealth program to prevent unnecessary rehospitalizations: Signs / symptoms secondary to treatment: Importance of fluid intake: Nutritional needs: Importance of prescribed oxygen therapy to prevent compromised breathing: Energy conservation: Medication Back : Disease Management Back : Patient / caregiver verbalizes understanding of the following: 11
Nutritional / fluid intake: Oxygen therapy usage and purpose: Importance of discharge planning in preventing exacerbations of symptoms: Urinary ed / No Problem Signs / symptoms of UTI: Urinary incontinence: Foley catheter draining: Foley catheter size: Fluid intake: Patient / caregiver understanding of medication purpose, dosage, and side effects: Effectiveness of telehealth program to prevent unnecessary rehospitalizations: Signs / symptoms of UTI: Importance of fluid intake: Patient / caregiver Foley catheter care: Patient / caregiver Foley catheter irrigation: Importance of good peri-care: Bladder training: Importance of discharge planning in maintaining healthy urinary health: Medication Back : Disease Management Back : Importance of follow-up with appointments: Patient / caregiver verbalizes understanding of the following: 12
Signs & symptoms of UTI: Irrigation of Foley catheter: Change Foley catheter: Foley catheter care: Foley catheter irrigation: Change Foley catheter: Obtain urine lab specimen: Patient / caregiver demonstrates catheter irrigation: Patient / caregiver demonstrates catheter change: Wound ed / No Problem Ability of patient / caregiver to provide wound care: Effectiveness of medication purposes: Patient / caregiver understanding of medication purpose, dosage, and side effects: Understanding of prescribed diet: Signs / symptoms of wound infection: Patient / caregiver to perform wound care: Agency care guidelines & seeking appropriate medical attention: Importance of medication protocol: Medication Back : Disease Management Back : Importance of discharge planning in maintaining long term cardiac health: 13
Patient / caregiver verbalizes understanding of the following: Signs & symptoms wound infection: Wound care: Patient / caregiver wound care demonstration: Wound Page Not ed Per Plan of Care Wound #: Resolved Location: Type of Wound: Pressure Vascular Diabetic Surgical Trauma Stage: 1 2 3 4 NA Partial Thickness Full Thickness Size: Length: cm Width: cm Depth: cm Undermining/Tunneling: cm at o clock Drainage: Serous Yellow/Tan Serosanguineous Thin Purulent Thick Green Other Drainage Amount: Surrounding Tissue: Minimum Moderate Copious Other Pink Yellow Black Red Intact Non-intact Wound Bed: Other Pink Yellow Black Red Other Odor: Yes No Describe: 14
Procedure: Cleansed With: Rinsed With: Filled With: Covered With: Secured With: Tech: Sterile Clean Patient s Tolerance: Not Well - Comp Well - No Comp S/S of Infection: Redness Hot to Touch Increased Pain Elev. Temp Increased Drainage Increased Odor None Pressure Relieving Device(s): Yes No Instructions Given: Patient Concerning Caregiver Process Measures Not ed Heart failure symptoms identified and addressed timely; MD notified. Diabetic foot care; patient / caregiver education implemented Fall prevention implemented Depression prevention implemented Pain prevention implemented Patient / caregiver educated on high risk meds Potential medication issues identified; MD contacted Pressure ulcer prevention implemented Pressure ulcer treatment implemented using moist wound healing principles Supervision Supervision Completed No Supervision Employee name, if present: Present Not Present NA Care rendered per Care Plan? No Yes NA Supervisory visit onsite? No Yes NA Employee courteous? No Yes NA Progress toward ADL? No Yes NA Employee professional? No Yes NA Progress toward Functional Goals? No Yes NA Continue frequency at? No Yes NA Discipline Supervised: HHA LPN COTA PTA NA Outcomes met? No Yes NA Change in service/poc needed? No Yes NA Satisfied with services? No Yes NA Good patient/employee rapport? No Yes NA / / Perform for Comorbidities / Additional Diagnosis 15
ment Summary Goals Homebound Homebound Status Residual weakness Unable to safely leave home unassisted Dependent upon adaptive device(s) Needs assistance for all activities Confusion, unable to go out of home alone Severe SOB, SOB upon exertion Medical Restrictions Requires assistance to ambulate Progress Toward Nursing Goals Plan for Next Visit Discharge Planning Care Coordination (Other Care Providers) Visit Date/Time End Visit Date/Time Time not recorded on Visit Note Signature / Dates Patient Signature Unable to Sign Date Signed Clinician Signature Date Signed 16