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 nurs :Hassan_abdan

XYZ CORPERATION SKILLED NURSING FORM

Patient Name (Print)

Patient #

Employee Name (Print) Job Classification

I certify that the hours shown represent my total hours worked on this assignment, and that

they were properly verified by the client or by and authorized representative.

Patient Signature

I certify that the visits/hours shown below are correct and that the employee performed satisfactorily

Nurse’s Signature/Title:

County

Subjective Complaint:

Clinical Findings: T: AP: RP: Rasp: Weight Blood Sugar

Wound Size: L: W: Wound Location:

Size: Drainage Amount: Odor: S/S Infection:

A .Skilled Observation/Assessment (+) Problem Present (-) No Problem If “+” Comments in narrative

Visit Type

Scheduled

Admission Visit

Supervisory Visit

Post Hospital Assess

Unscheduled Visit

Discharge

Date Day Mileage

Start End

Time Arrived (AM/PM Circle one) Time Left (AM/PM Circle one)

Supplies used: Total Mileage

Specific: Instruction(s) Provided to: Patient Spouse Other:

Subject(s) Specifics Taught (Use Teaching Sheet for additional information)

C. Progress Note/Discharge Planning:

1. Goals this visit met? (purpose for visit accomplished?) Yes No

2. Pt. Response/Progress to date:

3. Date of next visit: Are visits being: Incr Decr Patient Notified? Yes No Patient aware of D/C Plans? Yes No

4. Next MD visit: Contact made with MD? Yes No Contact with other discipline? Yes No HHA PT OT ST MSW

What discussed/what ordered:

Pt. Rights Reviewed? Yes No Grievance Procedure Reviewed? Yes No

Reference

Code(s)

Achieved this encounter (Reference Codes):

1. New, further instruction required * Must always use explanation codes with

2. Ongoing, further instruction required Reference code 6

3. Instruction complete a. Physically unable to perform

4. Return Demonstration b. Pt/Caregiver chooses not to learn

5. Verbalizes Understanding c. Mental deficit inhibits comprehension

6. Unachievable d. Environmental obstacles prevent further progress.

Written Materials Provided

10. (All visits except Admission) Any change in functional status from previous visit? Yes No If “yes”, explain

11. Activity Level: Independent Assist Needed: Total: Moderate: Minimum: Homebound due to:

Equipment::

12. Mental status Oriented Comatose Forgetful Depressed Disoriented Lethargic Agitated Other:

13. Intensity: 1 2 3 4 5 (1 = no pain) W/ W/

Intermittent Sharp Constant Burning Aching RELIEVED WITH: Rest Meds Activity Position Change

B.SERVICES PROVIDED (Provide specific comment in narrative below)

Skilled Observation Adm. of Vitamin B12 Teach Diabetic Care

Foley Change Prep/Adam. Insulin Other Teaching

Wound Care/Dressing Teach Ostomy/IIeo Conduit Care Observe/Teach Medication Effects/Side Effects

Decubitus  Care Teach/ Adm . Tube Feeding Physiology/Disease Process Teaching

Venipuncture Teach Care Terminally Ill Assess Diet/Fluid Intake

Bowel/Bladder Training Teach/Adm IM Meds Diet Teaching

Digital Exam with Manual Removal/Enema Collection Lab Specimen Safety Factors

Chest Physio/Postural Drainage Diabetic Observation Univ. Prec. Utilized

Comments:

SUPERVISORY VISIT: HHA LVN/LPN Present Not Present POC reviewed: yes no POC revised: yes no Care plan followed yes noOther: Standard precautions observed Home situation change:

heart sounds

chest pains

neck vein distention

edema:

RUE ( ) LUE ( )

RLE ( ) LLE ( )

periorbital/sacral

peripheral pulses

RUE ( ) LUE ( )

RLE ( ) LLE ( )

lung sounds

rales/rhonchi

cough

dyspnea/SOB

orthopnea

sputum

3. GI: WNL

Last bowel movement

nausea/vomiting

pain/distention

bowel sounds

appetite

4. GU WNL

burning pain

distention/retention

frequency/urgency

hematuria

incontinent bladder

dysuria

color

amount

odor

catheter

decubitus/wound

jaundiced

pallor

rash/itching

turgor

cyanosis

6. MUSCULO-SKELETAL

balance/gait unsteady

weakness

pain

bed/chair bound

synocope/vertigo

headache

grasp: Right

Left

motion: upper ext.

lower ext.

tremors

pupilary reaction: Right

pupilary reaction: Left

8. PSYCH or SOCIAL: WNL

coping ability

9. SAFETY WNL

1. CARDIOVASCULAR: WNL 2. RESPIRATORY WNL Diet: 5.SKIN WNL 7. NERVOUS SYSTEM WNL

BP Lying Sitting Standing

R

L

AGENCY COPY

XYZ-MR-1002 (REV 5-99)

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