EL – SOC

This is a [textarea cols=2 rows=1]-year-old [checkbox name="sex" value="male|female"] with [checkbox name="diagnoses" value="COPD exacerbation resulting in increased shortness of breath|severe weakness|cough and decreased oxygen saturation levels|CHF exacerbation|"][textarea cols=50 rows=1].
Admitted to [textarea cols=30 rows=1] on [date name="date_admit" default="02-18-2023"] [checkbox name="box2" value="for|with|s/p"] [textarea cols=50 rows=2].
Discharged to HH on [date name="date_discharge" default="02-18-2023"].
Independent prior to hospitalization. Currently, there has been a change in the patient’s condition as evidenced by the [checkbox name="change" value="recent hospitalization|weakness|SOB|sugical wound|"][textarea cols=50 rows=1].
Patient referred to home health to receive the following services:
[checkbox name="services" value="assessment and teaching of new or exacerbated condition|medication assessment and education|wound care|new ostomy care and teaching|physical therapy|occupational therapy|speech therapy|"][textarea cols=50 rows=1].
Consent for care was received from the [checkbox name="consent" value="patient|caregiver|"][textarea cols=50 rows=1].
History collection and nursing assessment were hampered by [checkbox name="limited" value="cognitive changes|fatigue|poor effort|limited mobility|pain|"][textarea cols=50 rows=1].
Leaving home [checkbox name="leave" value="requires a supportive device such as crutches, canes, wheelchair, or walker|requires special transportation with a ramp, lift or another type of adaptation|requires assistance of another person but no available or willing caregiver to provide this assistance|medically contraindicated because of the high risk of infection d/t immunosuppression|medically contraindicated because of the high risk of infection d/t open or draining wound|medically contraindicated because of the high risk of infection d/t long-term steroid treatment|medically contraindicated because of the high risk of infection d/t chemotherapy|medically contraindicated because of the high risk of infection d/t to recent surgery|medically contraindicated because of the frequent hypoglycemia causing confusion, unconsciousness, and/or falls d/t insulin therapy|medically contraindicated because of the medical orders prescribing bed rest|medically contraindicated because of the medical orders to walk stairs only once a day|medically contraindicated because of the medical orders to keep a lower extremity elevated at all times|medically contraindicated because of the non-weight bearing lower extremity per medical orders|medically contraindicated because of the psychiatric illness|"][textarea cols=50 rows=1].
Leaving home requires a considerable and taxing effort for the patient since the patient [checkbox name="taxing" value="is bed bound|has poor vision|is unable to navigate stairs / steps safely to get out/in the place of residence|is unable to ambulate safely d/t weakness / decreased endurance|is unable to ambulate safely d/t dizziness|is unable to ambulate safely d/t poor balance and coordination|is unable to ambulate safely d/t ataxic gait|is unable to ambulate safely d/t obesity|is unable to bear weight on the lower extremity|is unable to safely use walker without cues|has trouble ambulating d/t severe unremitting pain despite pain management|is unable to sit for more than 5 minutes d/t pain|is disoriented to the environment d/t confusion|is disoriented to the environment d/t dementia|is disoriented to the environment d/t the history of CVA|has SOB with minimal exertion d/t CHF|has SOB with minimal exertion d/t COPD despite oxygen therapy|has SOB with minimal exertion d/t obesity|"][textarea cols=50 rows=1].
Supplies & equipment available at home: [checkbox name="supply_home" value="oxygen tank|dressing supplies|wound vac|"][textarea cols=50 rows=1].
Supplies & equipment provided by agency: [textarea cols=50 rows=1 default="none reported"].
Past medical history is inclusive of [checkbox name="pmh" value="anemia|bladder incontinence|CAD|COPD|NIDDM|"][textarea cols=50 rows=2].
Past surgical history: [textarea cols=50 rows=1 default="none reported"].
Drug allergies: [checkbox name="allergy" value="none reported|recorded in POC|"][textarea cols=50 rows=1].
Laboratory and diagnostic tests [checkbox name="labs" value="reviewed|no critical values|are not available for review|"][textarea cols=50 rows=1].
Patient is [checkbox name="oxygen" value="not on O2|on O2 via NC|"][textarea cols=50 rows=1].
Patient [checkbox name="dm" value="does not have diabetes|was diagnosed with diabetes|is taking oral medications|is on insulin|appears compliant with glucometer|able to demonstrate BS log|"][textarea cols=50 rows=1].
Diet: [checkbox name="diet" value="regular|1800 ADA|renal|low sodium|no added salt|heart healthy|high protein|low protein|high carb|low carb|nut-free|lactose free|high fiber|fluid restriction|mechanical soft|finger foods|per hospital discharge notes|as stated by patient|not identified in discharge notes|"][textarea cols=50 rows=1].
Activities permitted: [checkbox name="activity" value="independent at home|up as tolerated|out of bed with assist|transfer bed-chair|exercise prescribed|bed rest with BRP|complete bed rest|"][textarea cols=50 rows=1].
Functional status: [checkbox name="functional" value="requires assistance with most ADLs|hard of hearing|based on direct observation|as reported by pt/cg|cannot be directly assessed d/t pt’s poor effort|"][textarea cols=50 rows=1].
Patient reports being [checkbox name="continent" value="continent of bladder|incontinent of bladder|continent of bowels|incontinent of bowels|"][textarea cols=50 rows=1].
Pain [textarea cols=20 rows=1].
Weight: [checkbox name="wt" value="weighed at home|reported by patient|obtained from SOC in last 30 days|cannot be measured due to extreme pain|cannot be measured due to risk of fall|"][textarea cols=50 rows=1].
Currently: [checkbox name="currently" value="A&O|vital signs WNL|unsteady gait|uses walker|dyspnea with minimal exertion reported by patient|dyspnea with minimal exertion observed by SN|lung sounds decreased but clear on both sides|skin grossly intact|2+ pedal edema|"][textarea cols=50 rows=2].
[checkbox name="orient" value="Patient|Caregiver"] was oriented to home health care including agency services and policies, patient rights and responsibilities, privacy policies, 24-hour on call availability, consent for treatment, advance directives, grievance procedure, insurance coverage, visit frequency. [checkbox name="accident" value="Patient|Caregiver"] received instructions on fall/accident prevention measures including keeping walkways clear of furniture and other obstacles, placing non-slip mats under rugs, keeping entrances and common areas well lit, placing things (glasses, phone, etc.) within easy reach. [checkbox name="pain" value="Patient|Caregiver"] received instructions on pain prevention and relief measures including monitoring pain status, frequent position changes, good body alignment, correct body mechanics, and taking pain medications if prescribed. [checkbox name="ulcer" value="Patient|Caregiver"] received instructions on methods to prevent pressure ulcers. [checkbox name="other" value="Patient|Caregiver"] was instructed on [checkbox name="box_5" value="sharps disposal|oxygen safety|bleeding precautions|seizure precautions|would care|safe use of walker|depression interventions|disaster preparedness/emergency planning, evacuation plan established, patient will"] [textarea cols=50 rows=1].
Evaluation method used to determine learning: [checkbox name="evaluation" value="return demonstration|asking relevant questions|"][textarea cols=50 rows=1].
[checkbox name="other3" value="Patient|Caregiver"] verbalized understanding of the skilled teachings provided but was unable to demonstrate complete understanding. Will benefit from continued SN services for reinforcement in teachings.
Rehabilitation potential is [checkbox name="potential" value="good|fair|poor|guarded"]. Discharge to [checkbox name="dc" value="family|caregiver care|self-care|ALF|"][textarea cols=20 rows=1] when [checkbox name="gohome" value="goals are met|there is no further benefit from continued HH services|knowledge deficits are addressed|wound shows signs of healing|patient is independent in medication management|"][textarea cols=50 rows=1].

Patient was visited on [date name="variable_1" default="02-26-2023"].
Patient lives [checkbox name="lives" value="in an apartment|in a house|in ALF|"][textarea cols=10 rows=1] [checkbox name="with" value="alone|with an adult child|with a spouse|"][textarea cols=10 rows=1].
Patient [checkbox name="reportcg" value="reports no caregivers willing and able to assist in care|reports no available caregivers|reports being unable to perform wound care|requests instruction on wound care|requests instruction on proper aseptic wound technique and infection control|"][textarea cols=50 rows=1].
Medically necessary skilled nursing care was provided during today’s visit including [checkbox name="skills" value="comprehensive skilled nursing assessment|medication reconciliation, including drug-drug interaction check|patient education|wound care|"][textarea cols=50 rows=1].
All medications were reconciled with instruction given on the dose, route, frequency, use, side effects, and potential interactions of each of their medications. [checkbox name="box_7" value="Patient|Caregiver"] verbalized understanding of these instruction.
Comprehensive assessment identified a need to provide medically necessary skilled nursing care to this patient. This home health plan of care (POC) includes [checkbox name="poc" value="SN services|physical therapy to evaluate and treat as well as assess the need for HHA services|wound care|"][textarea cols=50 rows=1].
[checkbox name="box_7" value="Patient|Caregiver"] engaged in the development of the plan of care, verbalized understanding of POC and discharge plan, consented to the proposed POC, and verbalized the following patient-centered specific goal: "[textarea cols=50 rows=1]." The steps toward attaining this personal goal are: "[textarea cols=50 rows=1]."
Patient’s risks for emergency room use and/or hospitalization include [checkbox name="barier" value="recent changes in health status|advanced age|h/o multiple recent hospital admissions|recent fall|recent unintentional weight loss|current infection|multiple ER visits and/or hospitalizations in the past 6 months|recent decline in mental, emotional, or behavioral status|h/o poor compliance and/or effort with medications, and/or medically ordered treatments|polypharmacy (5 or more medications)|persistent fatigue|overwhelming pain|poor health literacy|poor nutrition|wound or pressure ulcer|"][textarea cols=50 rows=1].
Measures to prevent emergency room use and/or re-hospitalization include [checkbox name="stayout" value="following the POC|physical therapy|patient education|wound care|"][textarea cols=50 rows=1].

Goals:
[checkbox name="box_8" value="Patient|Caregiver"] will verbalize or demonstrate understanding of their disease process, medication regimen, s/s of condition / disease exacerbation, infection control measures, home safety, emergency plan / evacuation, and when to communicate changes in health status with their physician and the agency to prevent re-hospitalization.
Patient’s vital signs will remain within the following parameters, unless there is a physician’s order dictating alternate acceptable parameters:
•	Temp <96 and >101
•	Pulse <60 and >120
•	Respirations <10 and >26
•	O2 Saturation level <89%
•	Systolic BP <80 and >170
•	Diastolic BP <50 and >100
•	Pain level >7   
•	Fasting BS <60 and >300   
Patient’s physician will be notified of any vital signs outside of these parameters.
Clinical staff to assess the patient’s disease process(es) and overall health condition.
[checkbox name="box_9" value="Patient|Caregiver"] to be instructed on the disease / condition process, s/s of exacerbation, medication regimen (to include dosage / route / frequency / contraindications / side effect), medication safety, and importance of receiving the recommended vaccinations and other preventative health measures.
[checkbox name="box_10" value="Patient|Caregiver"] to be instructed to immediately report to SN/PMD medical emergencies including severe pain, shortness of breath, difficulty breathing, chest pain unrelieved by rest, severe swelling in any part of the body, or any other unexpected s/s.
[checkbox name="box_11" value="Patient|Caregiver"] to be instructed to immediately report to SN/PMD any changes in their health status to help prevent re-hospitalization.  
[checkbox name="box_12" value="Patient|Caregiver"] to be instructed on safety measures including universal precautions, infection prevention and control, fire safety, and emergency plan / evacuation.
[checkbox name="box_13" value="Patient|Caregiver"] verbalized understanding of these instruction.
[checkbox name="box_14" value="Patient|Caregiver"] received the following written instructions: “How to prevent infection at home,” “Accident prevention,” and “Medication safety.”
Communication Per Agency Procedure:
Notify DON of admission. Coordinate care with the DON, scheduler, and all applicable therapies. Contact MD/representative to notify of admission, update on patient’s status and vital signs, confirm all diagnoses and medications, clarify any clinically significant medication issues, and confirm verbal orders for the plan of care. Agency may also accept orders from all the ordering doctor’s practice associates, as well as from [textarea cols=50 rows=1].
The agency may re-certify this patient for continued skilled services when a skilled need continues to exist at the end of the episode. Agency may Resume care upon discharge from a Hospital or Skilled Nursing Facility.

I certify that this patient is confined to his/her home and needs skilled services.
SN assessed the patient for COVID-19 symptoms. Patient questioned whether they had a fever, cough, SOB, loss of taste of smell, or generalized pain. Patient denied any symptoms. Patient instructed on COVID-19 symptoms, transmission, and prevention.

COVID-1 9 QUESTIONS
Have you or any of your caregivers/family traveled outside of the country or been on a cruise ship in the last 14 days? No
Have you or any of your caregivers/family been in contact with anyone who is a confirmed C0VID-19 positive patient in the past 14 days? No
Have you or any of your caregivers/family had the following symptoms in the past 14 days: Fever with a cough and shortness of breath? No

Bill of Rights/Advanced Directives
Prior to furnishing care, the patient was provided with a written notice of the patient’s rights and responsibilities (patient bill of rights) and Transfer and discharge policies. Both policies were reviewed by patient, and understanding was verbalized. The patient was further instructed that if at any time they have any questions, concerns, or do not understand their bill or rights or the transfer and discharge policies, to contact our office. They were also instructed, that if they do not understand the language this information is presented in, they will be provided a copy in the language of their choice for their understanding free of charge. If needed persons who have limited English proficiency and information can be made accessible to individuals with disabilities.

The patient was given the contact information for the Clinical manager and HHA administrator, including the administrator’s name, business address, and business phone number during the initial evaluation, prior to furnishing patient care. At the same time, an OASIS privacy notice was given to the patient.

Patient involved in and agreed with the POC and frequencies established at the SOC assessment.

Patient's emergency and an evacuation plan were reviewed with the patient at SOC assessment. Patient verbalized understanding of emergency and evacuation procedures at this time. The patient was also provided with information on advance directives at this time. All the above information remains in the patent’s orientation book for continued review as needed. Patient also has ACHC information to include 1-800 number and hours of operation.