Submit

SKILLEED NURSING VISIT NOTTE

Date:
MR No.:

Patient Naame:

Time In:

HOMEBOUN
ND REASON:
N
Needs
assistance for alll activities
Resiidual weakness
Requires assistance to ambulate
Confuusion, unable to go ouut of home alone
Unable to safely leavve home unassisted
Severe SOB, SOBB upon exertion
Depenndent upon adaptive device(s)
Medical restrictions
Other (specify):
CARDDIOVASCULAR
PULMON
NARY
INTEGUMENTARYY
MUSSCULOSKELETAL
Chest Pain
Lungs
W
Warm
Dry Cool Chills
Poor Baalance
Edema:
RUE
LUE
SOB Dizzy
I
Intact
Limitedd Movement
RLE
LLE
Cough
W
Wound
Ulcer Incision
Chair or
o Bed Bound
Abnormaal Rhythm
Sputum
R
Rash
Itching
Walks with:
Pulses
Oxygen
T
Turgor
Anticoaggulant Therapy
WNL
W
WNL
Contracture Paralysis
WNL
Other:
O
Other:
WNL
Other:
Other:

Time Out:
O
SN
Medicare
SN & Supervisoryy
Suprv. Only

TYPE OF VISIT:
Medicaid
Other:

VITAL SIGNS
S
and WOUND ASSESSMENT
A:
O:
R:
HT:
WT:
Resp:
( REG/ IRR)
Pulse A:
R:
( REG/ IRR)
B/P
LYING
SITTTING
STANDINGG
RIGHT
LEFT
FBS /RBS:
via Glucometer
T:

Denote Location / Size

S of Wounds / Pressure Sores
S /Meas. Ext. Edema Bil.

GASTRROINTESTINAL
Bowel Souunds
Abdomen Soft Tender
Distendedd
Nausea Vomiting
NPO
Diarrhea
Constipation
Incontinence
Ostomy:
PEG
Feeding
Flushing
Last BM
WNL
Other:

GENITOURINARY
Burning Dyysuria Odor
Distention Retention
Frequency Urgency
Incontinennce Hesitance
Itching
Color:
Catheter:
FR:
CC:
Last Changed
Irrigation
WNL
Other:

NEUROLOGICAL
H
Headache
S
Syncpe
Vertigo
Grassp: Equal Unequal
M
Movement:
Puppils: Equal Uneequal
H Tremors
Hand
A
Aphasia
Dysphaasia
S
Speech
Impairment
H
Hearing
Impairment
V
Visual
Impairment
W
WNL
O
Other:

MENTAL
Orienteed X:
Forgetfful
Confused
Disorieented
Letharggic
Comatose
Restlesss
Agitated
Anxiouus
Depressed
Alteredd LOC
Impaired Memory
Psych HX
H
WNL
Other:
#1

#2

#3

#44

Length
Width

PAIN
No Pain
Less oftenn than DAILY
DAILY butt not constsnt
Constant
Pain Leveel (1-10):
Site:
Relieved w. Meds:
M
Yes

Other:

No

INTERVENTTIONS
TECHNIQUE(S) USEED
Skilled Assessm
ment
U
Universal
Precautionss
Foley Change Irrigation
A
Aseptic
Technique
Wound Ulceer Incision
P
Proper
Sharp Objects Disp.
Prep Adminn Insulin
P
Proper
Waste Disposaal
Injection: IM
SQ
Q of Glucometer
QC
PEG
GT Site
S Care
G
Glucometer
Calibr:
Diet
Med Instruction
O
Other:
S/S Disease Proocess
Other:
SKILLLED INTERVENTION
N & TEACHING

INFUUSION / IV SITE
IV Tubiing Change
Cap Change
Catheter Site Change
IV Site Change
From:
To:
Med:
Rate:
VIA:

SN ADMINISSTERED
IM/SQ
CONTINUE TO
T VISIT FOR: OBSEERVATION ASSESS INSTRUCTIONS FOLEY
WOUNDD CARE LABS PREP
P
ADMIN INJECTION MAX TEACHING
T
ATTAINED
REINSTRUCT UNAATTAINED
N/A | RAANGE: High:
Low:
QUALITY COONTROL / GLUCOSE CONTROL SOLUTION
N
Expiration Date:
D
| Date Open:
| Control Indiicator:
PT/CG veerbalized understandiing of instructions givven | Compliant with Present Prioor Instructions
PT/CG abble to demonstrate coorrect Technique/Proccedure
PT unable too perform woundd care | administer injection due to:
CG unable too: perform wound care | administerr injection due to
No able CG
C available at this time to assist with:
Treatment/injection tolerated well by patient Compliant with Diet Compliant with Medication
M
Regimen
PT ability with Oral Meds:
Unable Able
Demonstrates
D
Understtanding
Supplies Useed: Syringes 0 Lancets
L
N/S Gloves Alcohol Pads Glucometer Strips 4x4 Other:
Dischargge Planning Discussedd:
Nurse Printeed Name:

Nurse Siignature:

RN

Depth
Drainage
Tunneling
Odor
Sur. Tis.
Edema
Stoma

CHANGE IN PATTIENT CONDITION

N/A
MD Notified (name):
Supervisor Notiffied:
Yes
No
N/A
New Orders / Comments:
Yees
No

SUPERVISORY VISITS
V

N/A |

LPN |
Yes

HHA
No

Following Care Plan

P
Patients Needs Met
M
Assignment Upddated
Service Chsnge Request
R
Univ. & Safety Prec. Followed
Employee Present
Patient Satisfiedd With Service
Comments:
LPN
Caring Partners Hom
me Care Agency, LLC | Form SNV001 | Revised 12//09