The following were discussed with the patient and/or caregiver prior to provision of care
- Rights and responsibilities
- Charges for services
- Pt/caregiver development of care plan
- Complaint procedure
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- Goals of visits
- Services provided
- Discharge planning
- EVV
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- Fire/safety/disaster emergency plan
- Privacy notice
- Instructions on measures to control infection
- Advance directive
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Diagnosis:
Prognosis: Good Fair Poor
Allergies:
Advanced Directive Yes No If yes, list:
Mental Status: Oriented Confused Forgetful Other
IMMUNIZATIONS
Influenza Vaccine:
Reason:
Pneumonia:
VITAL SIGNS
Temp: Pulse: Blood Pressure: Resp: Weight: Height:
Pain Scale: Pain location: Pain Description:
Intervention:
Effectiveness
Functional Limitations:
Ambulation Bowel/bladder (incontinence) Hearing Endurance Dyspnea Vision Others (specify)
Activities Permitted: Up as tolerated transfer bed/chair cane wheelchair walker Others (specify)
Any falls within the last 6 months? Yes No
List safety measures/Precautions:
Fall precaution Keep pathways clear Bleeding precautions Oxygen precautions Infection/standard precaution Others (specify)
Family supportive: Yes No Caregiver Name: Relationship:
Medication Management Self Family/Friend Other agency (name: )
DME and supplies
CANE WALKER WHEELCHAIR GRAB BARS BEDSIDE COMMODE TUB/SHOWER BENCH HOSPITAL BED OXYGEN HOYER LIFT RAISED TOILET SEAT DIABETIC SUPPLIES OTHERS
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