Florence Home Health Care. SKILLED NURSING NOTE. PURPOSE OF VISIT: PULSE: R A R/I RESPIRATIONS . R/I TEMP:_____ F O/R/A BP: Sitting ____/_____ L/R Sta...
Skilled Nursing Note [ ] Initial Assessment [ ] Follow up visit [ ] Supervisory visit Name of Patient: _____ Date: _____
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Florence Home Health Care
SKILLED NURSING NOTE
PURPOSE OF VISIT: PULSE: R A R/I RESPIRATIONS TEMP:______F O/R/A BP: Sitting ____/_____ L/R Standing ____/____ L/R Lying ____/____ L/R WEIGHT_____ lb Stated/Actual MENTAL: Agitated
No problem assessed at this time Aphasia Slurred Speech Seizures Headache Tremors NEUROLOGICAL: Vertigo Change in LOC Grips Unequal Pupils Unequal Numbness Visual Deficit Hearing Deficit Speech Deficit Comments: _____________________________________________________________________________________________________________ No problem assessed at this time Pedal Pulses: Present Absent Edema: None Pitting Non-Pitting CARDIOVASCULAR: Chest pain Palpitations Dizziness Orthopnea Location/Amount: _____________________________________ Comment: _______________________________________________________________________________________________________________ No problem assessed at this time Lung Sounds: ____________________________________________________________ RESPIRATORY: Cough: Prod Non-Prod O2____LPM/NC/Mask SOB: Rest Min Exertion Sputum: Color ____________ Amt ______________ Oxygen Saturation: ________% Comment:____________________________________________________________________________________ No problem assessed at this time Appetite: Good Fair Poor Bowel Sounds: Present Absent GASTROINTESTINAL: Hypo Hyper Nausea Vomiting Diarrhea Constipation Incontinent Last BM ________ Feeding Tube ___ Diet: Comment: ________________________________________________________ No problem assessed at this time Incontinent Frequency Urgency Pain on urination GENITOURINARY: Nocturia Burning Retention FC Suprapubic Catheter/Size ___ F ______cc balloon Condom Catheter (S/M/L) Urine: Color _____________ Odor Cloudy Amount: _______ ml Comments: ________________________________________________ No problem assessed at this time Blood Glucose _____MG/dl random/fasting Per patient/PCG Diaphoretic Polyuria ENDOCRINE: Blurred Vision Polydipsia Polyphagia S/S of Hypoglycemia S/S of Hyperglycemia Tachycardia Comment: _______________________________________________________________________________________________________________ No problem assessed at this time Turgor: Good Fair Poor Skin Temp: Warm Hot Cold SKIN: Rash Diaphoretic Bruises Dry Excoriation Pallor Jaundice Pruritis Blister(s) Surgical wound Skin tear Stasis ulcer Pressure ulcer Diabetic Ulcer Site: _____________________________________ Drainage/Description/Amount: __________________________________________ Odor Skin on Feet Intact Perineal Area Intact Wound Sheet Q week completed Comment: ______________________________________________________________________________________________________________ No problem assessed at this time Stiff joints Painful joints Weakness ________________ Contractures MUSCULOSKELETAL: Unsteady Balance/Gait Comment: ________________________________________________________________________________________ No Yes Location ______________________________ Origin _____________________ Frequency _________________________ PAIN: Intensity 1 2 3 4 5 6 7 8 9 10 (circle) Sharp Dull Burning Radiating Controlled?: Yes No Pain med last given: _______ Current Pain Management: ____________________________ Comment: ___________________________________________________________ _______________________________________________________________________________________________________________________ No meds currently No problem assessed at this time Pt/PCG compliant with med regime Pt/PCG lacks knowledge MEDICATIONS: regarding med regime Medications are effective No drug interaction noted Started on new med ______________________ Med profile updated Comment: _________________________________________________________________________________________________ Abnormal Findings/Skilled Care Provided:
Standard Precautions observed
Infection Control Measures observed including handwashing
Two Identifiers used to verify Patient Safety Precautions Observed Medical Equipment in good working order Requires SN since: No willing and able CG to administer Insulin No willing and able CG to provide wound care/administer IM/IV medication Pt/PCG response: Pt/PCG verbalizes understanding of teaching _____ % Pt/PCG needs further instruction Pt/PCG demonstrated procedure properly w/o cues Pt/PCG demonstrated procedure w/ cues ___________________________________________________________ Communication with (name and title) _____________________________________________ Re: _______________________________________ No new orders at this time Medication change Treatment change Physician appointment Lab specimen obtained Plans for next Visit: _______________________________________________________________________________________________________ Needs assistance with all activities Residual Weakness Requires assistance to ambulate Medical restrictions Homebound Status: Confusion, unable to go out of home alone Unable to safely leave home unassisted Dependent upon adaptive device (s) Severe SOB, SOB on exertion Other (specify) ___________________________________________ Yes No Follows task/care plan? Yes No AIDE SUPERVISION: Name of Aide __________________ Aide present Patient satisfied with services? Yes No Cleans up work areas Yes No Uses good safety practice Yes No Aide Task Sheet updated? Yes No Care Observed ___________________________ Instructed in _________________________________ Patient Name Nurse’s Name
