Reason for Visit: Incident follow up Complaint follow up Post hospital Change in condition
Other reason for visit:
Temp:°F Pulse: Blood Pressure: /
Respirations: Pain scale: Select012345678910 No pain at this time
Location:
Description:
Intervention:
Effective: YES NO Comment:
Edema
Left Upper Extremities Right Upper Extremities
Left Lower Extremities Right Lower Extremities
Pacemaker: YES NO
Palpitations: YES NO
Anticoagulants: YES NO Intervention in narrative:
Alert and oriented to:
Person Place Time Situation
Periods of confusion
Affect/Behavior:
WNL Anxious Agitated Depressed Flat
Hallucinations Suicidal/Homicidal Ideation
Other
Lung Sounds
SOB: Yes No With exertion Without exertion
Oxygen use: Yes No
Skin integrity Intact Impaired
Decription/Intervention
Weight loss: Yes No
Diet:
Compliant: Yes No
Continent Bowel: Yes No
Continent Bladder: Yes No Other
Bowel Sounds:
Last B/M:
Blood glucose ranges: AM PM
Insulin dependent? Yes No
Insulin taken per MD order N/A
Steady With Device Unsteady
At risk for falls: Yes No
Fall Precautions & Interventions – include in the MD orders and plan of care and narrative (modifiable risk factors, teaching etc.)
ADL/IADL
Assist with: Toileting Bathing Feeding Other
PRIORTY CODE Select123 TALS Select1 - Non ambulatory Stretcher1 - Non ambulatory Vent1 - Non ambulatory Bariatric2 - Wheelchair3 - Ambulatory
Post Hospital or Follow-Up Treatment changes ordered:
Medication Changes (New or D/C) Yes No N/A
I have reviewed the medications to identify any potential adverse effects, drug parameters and drug reactions including ineffective drug therapy, significant side effects, significant drug interactions and duplicate drug therapy.
MEDICATION COMPLIANCE Yes No
Comments:
Medications Administered by:
Functional Limitations: 1- Amputation 2-Bowel/Bladder(Incontinence) 3-Contracture 4-Hearing 5-Paralysis 6-Endurance 7-Ambulation 8-Speech 9 - Legally Blind 10 - Dyspnea with minimal exertion 11 - Other interventions Notification for changes Yes No
Patient lives in: House Rooms Apartment Senior Citizen Housing Family Care/Foster Home /Shelter Other
Patient lives with: Patient lives alone
Indicate if any of the above (including their location/primary caretaker availability) affect the ability of the Patient to function safely in home or to get outside:
Indicate if any of the above (including their location /primary caretaker availability) will affect the need for and delivery of services in the home:
Comments/other environmental findings :
POC update needed: Yes No
POC copy left in the home: Yes No
Educated Aide/Reviewed Plan of Care:
Is the aide present Yes No
Orientation and supervision is performed in this visit or telephonic orientation to plan of care and changes
Orientation/ supervision : PCA HHA Name:
Instructed about Client's health condition and how it may affect provision of tasks.
Instructed about tasks to be provided, work schedule, and safety and emergency procedures.
Instructed to report to Agency the following changes in patient condition:
Instructed to report the following to the Agency as soon as possible
Aide’s Name: Type of Service: PCAHHA
Aide able to communicate with patient and comprehend the plan of care. YES NO
Aide instructed on following POC and documenting care provided.
Progress Notes:
Also submit to the Coordination department
Additional Instruction/ teaching completed: Progress Note:(include interventions, client teaching provided, case coordination with agency personnel and any additional follow up referrals or coordination of care with MD or other providers )
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Patient Unable To Sign
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Time out: AMPM
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