The SOAPnote Project > Nursing > EL – SN

EL – SN

posted 2023-03-04, updated 2023-03-11

Tags: HOME HEALTH, skilled nursing visit

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TYPE OF VISIT: [checkbox name="type" value="SOC|ROC|REC|SN|Supervisory|"][textarea cols=5 rows=1].
Patient was visited at [checkbox name="location" value="home|ALF|"][textarea cols=5 rows=1].
Patient was observed [checkbox name="observed" value="sitting in living room|sitting on a couch|sitting in a recliner|watching TV|speaking on the phone|"][textarea cols=40 rows=1].

Patient is homebound d/t [checkbox name="homebound" value="needing assistance for all activities|having residual weakness|requiring assistance to ambulate|being dependent upon adaptive device|having confusion, unable to go out of home alone|being unable to safely leave home unassisted|having severe SOB upon exertion|having medical restrictions|"][textarea cols=40 rows=1].

Interval change (since last SN visit):
Medication change? [checkbox name="Rxchange" value="No|Yes"]
New physician orders? [checkbox name="MDorders" value="No|Yes"]
PCP visit? [checkbox name="PCPvisit" value="No|Yes"]
Specialist visit? [checkbox name="specialty" value="No|Yes"]
New labs? [checkbox name="labs" value="No|Yes"]
New or unusual symptoms? [checkbox name="newsx" value="No|Yes"]
[textarea cols=50 rows=4]

Reports [checkbox name="pain" value="no pain|pain less often than daily|pain daily but not constant|constant pain|which interferes with activity and/or movement|which is relieved with meds|which is not relieved with meds|"] [textarea cols=30 rows=1 default="pain"].

ENDOCRINE:
Patient [checkbox name="endocrine" value="does no have diabetes|has diabetes and takes oral medications|has diabetes and is on insulin therapy|is compliant with glucometer|administers their own insulin|has insulin administered by a caregiver|"][textarea cols=30 rows=1 default="diabetes"].

CV:
Patient [checkbox name="cvs" value="denies chest pain|is on an anticoagulation|has regular heart sounds|has strong peripheral pulses|demonstrates good capillary reﬁll|"][textarea cols=30 rows=1].
Lower extremity exam reveals [checkbox name="le" value="no edema|no stasis discoloration|no open wounds|"][textarea cols=50 rows=1].
PULMONARY:
Patient [checkbox name="lung" value="is on room air|displays dyspnea with minimal exertion|is coughing|has normal lung sounds throughout|has decreased lung sound throughout|"][textarea cols=50 rows=1].
GASTROINTESTINAL:
Patient reports [checkbox name="gisub" value="nausea|diarrhea|constipation|incontinence|no GI concerns|last BM"] [textarea cols=10 rows=1]. Exam reveals [checkbox name="abd" value="soft|non-distended|distended|tender"] abdomen and [checkbox name="bs" value="present|decreased|increased"] bowel sounds. [textarea cols=50 rows=1].
GENITOURINARY:
Patient reports [checkbox name="gusub" value="normal urinary pattern|frequency|urgency|retention|incontinence|"][textarea cols=30 rows=1]. Exam reveals [checkbox name="bladder" value="no suprapubic tenderness|dark yellow urine|light yellow urine|"][textarea cols=50 rows=1].
MUSKULOSKELETAL:
Patient uses [checkbox name="ambul" value="cane|walker|"][textarea cols=30 rows=1] to ambulate. Patient was observed to have [checkbox name="balance" value="poor balance|DROM in"] [textarea cols=30 rows=1].
NEUROLOGICAL:
Patient reports [checkbox name="neurosub" value="dizziness|headaches|"][textarea cols=30 rows=1]. Exam reveals [checkbox name="neuroob" value="good hearing|good vision|hearing impairment|visual impairment|hand tremor|dysphasia|equal grasp|"][textarea cols=50 rows=1].
MENTAL STATUS:
Patient appears [checkbox name="mental" value="forgetful|anxious|irritable|restless|depressed|lethargic|confused|"][textarea cols=30 rows=1].
INTEGUMENTARY:
Skin [checkbox name="skin" value="dry|moist|cool|warm|flushed|"][textarea cols=30 rows=1].

SKILLED INTERVENTIONS:
[checkbox name="skilled" value="nursing assessment|med box fill|urinary catheter change|insulin administration|glucometer calibration|injection|feeding tube site care|wound care|"][textarea cols=30 rows=1]. Patient tolerated intervention well.

[checkbox memo="TF" name="tf" value=""][conditional field="tf" condition="(tf).is('')"]TUBE FEEDING:
Type: [textarea cols=10 rows=1]
Rate: [textarea cols=10 rows=1]
Residual: [textarea cols=10 rows=1]
Placement: verified
Formula: [textarea cols=20 rows=1][/conditional]

[checkbox memo="CATH" name="cath" value=""][conditional field="cath" condition="(cath).is('')"]URINARY CATHETER:
Type: [textarea cols=20 rows=1 default="Foley suprapubic"]
Size: [textarea cols=2 rows=1] Fr
Ballon: [textarea cols=2 rows=1] mL
Cath: [textarea cols=20 rows=1]
Drainage bag: [textarea cols=20 rows=1 default="changed"][/conditional]

[checkbox memo="IV" name="iv" value=""][conditional field="iv" condition="(iv).is('')"]IV THERAPY: [textarea cols=30 rows=3 default="PIV PICC"]
Prior to administration, the catheter was flushed with _______ of NS
Medication administered _________ at ____________
After medication administration, the catheter was flushed with ______________
Patient tolerated procedure well
[/conditional]

[checkbox memo="WOUND" name="wound" value=""][conditional field="wound" condition="(wound).is('')"]WOUND CARE: [checkbox name="wc" value="old dsg removed|wound cleansed with NS|"][textarea cols=50 rows=3][/conditional]

SAFETY:
[checkbox name="safety" value="reassessed home for safety hazard|no safety hazards identified|cluttered environment|loose rugs|"][textarea cols=30 rows=1].

Patient caregiver instructed on [checkbox name="instructed" value="S/S disease process|medication regimen (including side effects and adverse reactions)|diet|methods to promote hydration and appropriate oral intake|interventions to prevent pressure ulcers|coping methods||nebulizer administration|diabetic skin care/foot care|fingerstick blood sugar monitoring|preparation & administration of insulin|catheter care|ostomy care|wound care|bowel and bladder training||home safety|fall precautions|infection control measures (sharps/waste disposal)|anticoagulation precautions|seizure precautions|care of O2 equipment|911/emergency measures|"][textarea cols=30 rows=1].

Patient caregiver was provided with opportunity to ask questions, verbalized understanding, will need reinforcement of teaching.

USED:
[checkbox name="used" value="universal precautions|aseptic technique|proper waste disposal|proper sharp objects disposal|"][textarea cols=30 rows=1].

Coordinate care with the DON, scheduler, and all applicable therapies. Patient Caregiver consented to continuous receiving HH. I certify that this patient is confined to his/her home and needs skilled services.

TYPE OF VISIT: SOC ROC REC SN Supervisory

.
Patient was visited at home ALF

.
Patient was observed sitting in living room sitting on a couch sitting in a recliner watching TV speaking on the phone

.

Patient is homebound d/t needing assistance for all activities having residual weakness requiring assistance to ambulate being dependent upon adaptive device having confusion, unable to go out of home alone being unable to safely leave home unassisted having severe SOB upon exertion having medical restrictions

.

Interval change (since last SN visit):
Medication change? No Yes
New physician orders? No Yes
PCP visit? No Yes
Specialist visit? No Yes
New labs? No Yes
New or unusual symptoms? No Yes

Reports no pain pain less often than daily pain daily but not constant constant pain which interferes with activity and/or movement which is relieved with meds which is not relieved with meds

.

ENDOCRINE:
Patient does no have diabetes has diabetes and takes oral medications has diabetes and is on insulin therapy is compliant with glucometer administers their own insulin has insulin administered by a caregiver

.

CV:
Patient denies chest pain is on an anticoagulation has regular heart sounds has strong peripheral pulses demonstrates good capillary reﬁll

.
Lower extremity exam reveals no edema no stasis discoloration no open wounds

.
PULMONARY:
Patient is on room air displays dyspnea with minimal exertion is coughing has normal lung sounds throughout has decreased lung sound throughout

.
GASTROINTESTINAL:
Patient reports nausea diarrhea constipation incontinence no GI concerns last BM

. Exam reveals soft non-distended distended tender abdomen and present decreased increased bowel sounds.

.
GENITOURINARY:
Patient reports normal urinary pattern frequency urgency retention incontinence

. Exam reveals no suprapubic tenderness dark yellow urine light yellow urine

.
MUSKULOSKELETAL:
Patient uses cane walker

to ambulate. Patient was observed to have poor balance DROM in

.
NEUROLOGICAL:
Patient reports dizziness headaches

. Exam reveals good hearing good vision hearing impairment visual impairment hand tremor dysphasia equal grasp

.
MENTAL STATUS:
Patient appears forgetful anxious irritable restless depressed lethargic confused

.
INTEGUMENTARY:
Skin dry moist cool warm flushed

.

SKILLED INTERVENTIONS:
nursing assessment med box fill urinary catheter change insulin administration glucometer calibration injection feeding tube site care wound care

. Patient tolerated intervention well.

TF

CATH

IV

WOUND

SAFETY:
reassessed home for safety hazard no safety hazards identified cluttered environment loose rugs

.

Patient caregiver instructed on S/S disease process medication regimen (including side effects and adverse reactions) diet methods to promote hydration and appropriate oral intake interventions to prevent pressure ulcers coping methods nebulizer administration diabetic skin care/foot care fingerstick blood sugar monitoring preparation & administration of insulin catheter care ostomy care wound care bowel and bladder training home safety fall precautions infection control measures (sharps/waste disposal) anticoagulation precautions seizure precautions care of O2 equipment 911/emergency measures

.

Patient caregiver was provided with opportunity to ask questions, verbalized understanding, will need reinforcement of teaching.

USED:
universal precautions aseptic technique proper waste disposal proper sharp objects disposal

.

Coordinate care with the DON, scheduler, and all applicable therapies. Patient Caregiver consented to continuous receiving HH. I certify that this patient is confined to his/her home and needs skilled services.