EL – DC

D/C summary completed by SN on [date name="variable_1" default="03-11-2023"].
This is a [textarea cols=2 rows=1] y/o [checkbox name="sex" value="male|female"] has been receiving HH care since [date name="variable_1" default="03-11-2023"]. Prior to SOC, this patient [checkbox name="hpi" value="had increasing pain|had a fall|difficulty with ambulation|DROM|SOB|surgery|was diagnosed with|was discharged from hospital to HH|"][textarea cols=50 rows=3].

Patient required home health care for [checkbox name="why" value="VS monitoring|wound care|PT|OT|ostomy care|skilled teaching on knowledge deficits|"][textarea cols=30 rows=1].

Patient was homebound d/t [checkbox name="homebound" value="needing assistance for all activities|having residual weakness|requiring assistance to ambulate|unsteady gait|being dependent upon adaptive device|having confusion, unable to go out of home alone|being unable to safely leave home unassisted|dyspnea with minimal exertion|having medical restrictions|"][textarea cols=10 rows=1].

The following services has been provided: [checkbox name="services" value="SN|PT|OT|ST|"][textarea cols=10 rows=1]. Patient received [textarea cols=40 rows=1] visits.

Last MD visit: [textarea cols=20 rows=1].

Discharge: [checkbox name="discharge" value="complete - discharged from all home health services|partial - discharged from skilled nursing, will continue|"] [textarea cols=20 rows=1].

Goals achieved: [checkbox name="goals" value="patient remained afebrile|patient maintained VS in therapeutic range|disease symptoms controlled by appropriate therapy|FBS stayed within therapeutic range|patient had no falls|patient had no hospitalizations|patient maintained SOC weight|patient has maintained skin integrity|patient has not developed new pressure ulcers|wound has been healing well without complications|incision has been healing without complications|patient improved mobility|patient became more independent with ADLs|patient increased ROM|patient demonstrated increased independence in self-care|patient verbalized knowledge of disease process|patient verbalized knowledge of medications, side effects, precautions|patient verbalized knowledge of s/s necessitating medical attention|caregiver verbalized knowledge of disease process|caregiver verbalized knowledge of medications, side effects, precautions|caregiven verbalized knowledge of s/s necessitating medical attention|"][textarea cols=30 rows=1].

Concerns remaining:	[checkbox name="concerns" value="poor response and adherence to teaching|repetitive teaching required|home environment/difficulty with ambulation|difficulty communicating with health care provider|high risk of fall|polypharmacy|oxygen safety|risk for bleeding|infection control|disaster preparedness|"][textarea cols=30 rows=1].

Pain: Patient rates pain [textarea cols=2 rows=1] [textarea cols=20 rows=2 default="Patients reports satisfactory pain management"].

Reason for discharge: [checkbox name="dcreason" value="goals met|patient achieved maximum potential of skilled services|declined further services|moved out of geographical area|expired|hospitalized|admitted to LTC|no longer home bound|physician canceled services|transferred to another agency|"][textarea cols=20 rows=1].

Condition on discharge: [checkbox name="condition" value="stable|improved|able to care for self|able to remain safely in residence|deceased|institutionalized|"][textarea cols=20 rows=1].

[checkbox name="xxx" value="Patient|Caregiver"] instructed on [checkbox name="instructed" value="disease process|s/s of complications|taking medications as prescribed|action & side effects of meds|diabetic management|skin care|wound care|Foley care|prescribed treatments|activity restrictions|PMD follow up|"][textarea cols=40 rows=1].

[checkbox name="xx3" value="Patient|Caregiver"] verbalized understanding of discharge plan.

Discharge discussed/care coordinated with [checkbox name="coord" value="patient|family|agency care manager|"][textarea cols=20 rows=1]. Office to fax a DC summary to the attending physician.