PRN Nursing Visit


Client Name:      Date of Birth:  
     Visit Date:  
  Time:


Reason for Visit:              

       Other reason for visit: 

VITAL SIGNS

Temp:°F   Pulse:  Blood Pressure: / 

Respirations: Pain scale:  

Location:

Description:

Intervention:

Effective:    YES      NO

CARDIOVASCULAR

Edema

Pacemaker: YES      NO

Palpitations: YES      NO

Anticoagulants: YES      NO
Intervention in narrative:

 
MENTAL STATUS

Alert and oriented to:

   Person   Place   Time   Situation

  Periods of confusion

Affect/Behavior:

 WNL   Anxious   Agitated   Depressed   Flat

  Hallucinations   Suicidal/Homicidal Ideation

  Other

RESPIRATORY

Lung Sounds

  SOB:   Yes   No   With exertion   Without exertion

  Oxygen use: Yes No

 

 

 

 

 
SKIN INTEGRITY

Skin integrity   Intact   Impaired

Decription/Intervention

 

 

 DIET/ELIMINATION

Weight loss:   Yes   No

Diet:

Compliant:  Yes  No

Continent Bowel:  Yes  No

Continent Bladder:  Yes   No
Other

Bowel Sounds:

Last B/M:

ENDOCRINE

Blood glucose ranges:
AM PM

Insulin dependent?  Yes   No

Insulin taken per MD order  N/A

 

 

 

 Ambulation Status/Safety Assessment

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        TALS

Post Hospital or Follow-Up Treatment changes ordered:

Medication Changes (New or D/C)                     Yes  No  N/A

 

Name of Medication New D/C Dose Route Frequency /Parameters if applicable

 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

Medications Administered by:

Comments:

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
HOUSEHOLD INFORMATION/FUNCTIONAL ASSESSMENT/ENVIORNMENTAL RISKS

   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:

Environmental Checklist
 Yes    No
 Yes    No
 Yes    No
 Yes    No
 Yes    No
 Yes    No
 Yes    No
 Yes    No
 Yes    No
 Yes    No
 Yes    No
 Yes    No
 Yes    No
 Yes    No
 Yes    No
 Yes    No
 Yes    No
 Yes    No
 Yes    No
 Yes    No
 Yes    No
 Yes    No

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:

  • Changes in mental status
  • Falls, with or without injury
  • Skin changes
  • Other

 

Instructed to report the following to the Agency as soon as possible

  • Client hospitalized
  • Changes in the Client's needs and behaviors
  • Client's absence from home or has moved

 


 Aide’s Name:        Type of Service:

TREATMENT TASK OBSERVED QUALITY OF CARE
MAINTAINS INFECTION CONTROL
YES NO

Appropriate PPE
YES NO
 BATH
SKIN CARE
PERSONAL CARE		 EXCELLENT
GOOD
FAIR
POOR
KNOWLEDGEABLE OF TASKS
YES NO		 ORAL CARE
INCONTINENCE CARE		 AIDE COMMENTS:
NUTRITION
BED CARE
EXERCISE		 PATIENT/SIGNIFICANT OTHER COMMENTS:

IDENTIFICATION BADGE
YES NO
 BLOOD PRESSURE
PULSE RESP
TEMPERATURE
WEIGHT

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:

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 )
Patient Signature:

Reset Signature

Reason Patient unable to sign

If patient is unable to sign and this box is checked please enter N/A in the patient signature box

 Authorized Agent Signature:

Reset Signature


Print Name:
Relationship:

Aide Signature:

Reset Signature
RN Signature:

Reset Signature

Print Name

Today's Date

Time out:
 


         
 

Saved forms are only kept for 2 weeks, be sure to complete and submit the form before then
Be sure to enter your email and remember your password to continue this form