Visit type:[text name="text" default=" "] met with patient today for initial assessment Discussed hospice philosphy, services and benifits. After a thorough explanation of hospice concepts and goals, XXX signed consent. xxxverbalized full understanding and appreciated the services. Patient is XXXXXXadmitted to hospice care with terminal diagnosis of VVVVVVVVV He lives in a XXXXX with XXXXX Past medical history/ Comorbidities include: [checkbox name="diseases" value="Essent[ial Primary Hypertension|Diabetes Mellitus|Parkinson's Disease|GERD|Atrial fibrillation |generalized wekaness|Difficulty in walking|Pain|Age related physical debility|Atherosclerotic heart disease of the native coronary without agina|option A|option B|optionc|option d|E|F|G|H|I|J|K|L|M|n|option Coption A|option B|option C"] Previous hospitralization leading to hospice Patient is bed bound, ambulatory Received patient [checkbox name="condition" value="in bed|at the dayroom |Dining area|asleep|easily aroused|non responsive|responds to sound|responds to touch|respond so pain|awake|alert and oriented to |person|time|palce|situation|self only|in no apparent distress|patient is on continous oxygen at 2LPM via NC stating at___% |v3|v4|v5|v6|v7|v8"] Presents: Patient was [checkbox value="calm|cooperative|uncooperative with assessment|minimally cooperative with assessment|blunt|lethargic|fair grooming and hygiene|confused|anxious|agitated|pleasantly confused|forgetful|bright affect|cachectic|frail|debilitated|pale|weak|v6|v7|v8|able to follow command|needs a lot of prompting|able to verbalize needs|unable to follow command|unable to verbalize needs|bedbound|No reported of agitation or aggression. Minimal speech to non verbal today. |Patient continues to discuss childhood or younger year memories but has difficulty with short term memories not remembering what he ate for breakfast or recent events throughout the week. "] Patient Denies [checkbox value="chest pain,|shortness of breath,|pain|coughing|v2|v3|"]. Patient is observed [checkbox value="short of breath with minimal exertion,|shortness of breath with transfer,|short of breath with repositioning|pursed lips|short fo breath with speech|no apparent injury|No sign of pain or discomfort."]. Head to toe assessment was done: [checkbox name="assessment" value="Pupils equal, round and reactive to light|Patient has poor eye contact|eyes are closed|eyes are open but non reactive|able to follow object|poor visual tracking|Apical pulse normal rate and rhytym|Apical pulse aryhtmic|apical pulse weak|Radial pulse equal +1|pedal pulses weak|peal pulses absent|tachychardic|tachypneic|respiration regular and unlabored|labored breathing|cheyne stokes|Accessory muscles being used.|Radial pulse equal and palpable, |Pedal pulses equal and palpable|no edema|Bilateral Lower extrmities with non-pitting edema|left lower extremity __edema|right lower extremnity ___ edema|weeping edema|Skin is dry |Skin is moist|warm|cool|intact|Lungs clear to auscultation|no adventitious sound|Left lower lobe with fine crackles|right lower lobe with fine crackles|wheezing|diminished|upper lobes clear to auscultation|Abdomen|soft|firm|non-tender|tender on left lower quadrant|bowel sound heard on all quadrants|cathether is patent|no limitations on range of motion from baseline|____mild contraction|severley contracted|modertaley contracted|Trace edema noted in bilateral lower extremities. Legs elevated on recliner and educated GH caregivers on elevation to help with swelling. |tremors noted|v3|v4|v5|v6|v7|v8v8v8"] Patient reports: [checkbox name="REPORT" value="difficulty falling asleep |staying asleep|movingh bowel|walking|feeling weak|feeling tired|feeling hopeless|feeling sad|feeling ok|no interest in doing things|poor appetite|poor sleep quality|v1|PAIN at v3|pain is controlled by current medication|Hospice Medical Director was infomed , medication adjsutment was ordered|v6|v7|v8"] Caregiver reports [checkbox name="caregiver concern" value="poor appetite|consumes less than 40% of meals served|consumes less than 30% of meals served|consumes less than 20% of meals served|consumes less than 10% of meals served|Denies choking or problem swallowing. Noted increased confusion|sleeps almost 15 houra a day|sleeps almost 20 houra a day| does not sleep at night but take daytime naps|is agitated at night|has episodes of aggression| has difficulty moving bowel|is constiapated|has hard stool|patient needs a lot of prompting and enxouraging when eating |uanble to feed self|Able to feed self but needs prompting at times|increasing wekness|increasing coinfusion|increasing needs for assistance with mobility|transfer|toileting|bathing|dressing|feeding|ppetite apparently continuous to decreased, frequently declined to eat. | Pcg was instructed to give Ensure everyday for her supplement nutrition|v4|v5|v6|v7|v8"] Hospice goals were discussed, including all legal documents, thoroughly to the patient/family/caregivers, legal responsibilities and they agreed to hospice services thus all legal documents were signed respectively including consent to admit patient to[select name="Hospice 1" value="Compassionate|Uplift|Comfort Care"] Hospice. Provided Patient/Family/POA information regarding Bill of Rights and responsibilities, home safety, Safety medication tips, drug classification sheet teaching sheets, home use and disposal of controlled substances, infection control and prevention, signs and symptoms of infection, signs of impending death, hydration and nutrition, pain, home safety tips and guidelines, emergency preparedness guidelines, earthquake and disaster preparedness tips, keeping controlled medication in a secure and safe place as well as proper/safe disposal of controlled medication. Patient and family/poa or care giver verbalized understanding of information provided. Medications reconciled without any issues. Patient safety and fall prevention to be imposed at all times. Patient/family/ Caregivers verbalized understanding of instructions. Sn to visit patient for assessment and for symptom management. HHA to visit patient to assist with ADLS. MSW to assess patient and family regarding psychosocial needs and emotional status and to provide assistance in outside resources once a month. SC assess and visit patient once a month for spiritual needs. Offered volunteer services but they politely declined. Advised to call [select name="hospice" value="Compassionate Hospice|Uplift Hospice|Comfort Care Hospice"] for any patient concerns and changes in status 24/7. [select name="Medical Director" value="Dr. Acosta|choice B|choice C"]and all disciplines notified of new admission.
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