EL – SN

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:
.
Patient was visited at
.
Patient was observed
.

Patient is homebound d/t
.

Interval change (since last SN visit):
Medication change?
New physician orders?
PCP visit?
Specialist visit?
New labs?
New or unusual symptoms?


Reports
.

ENDOCRINE:
Patient
.

CV:
Patient
.
Lower extremity exam reveals
.
PULMONARY:
Patient
.
GASTROINTESTINAL:
Patient reports
. Exam reveals abdomen and bowel sounds.
.
GENITOURINARY:
Patient reports
. Exam reveals
.
MUSKULOSKELETAL:
Patient uses
to ambulate. Patient was observed to have
.
NEUROLOGICAL:
Patient reports
. Exam reveals
.
MENTAL STATUS:
Patient appears
.
INTEGUMENTARY:
Skin
.

SKILLED INTERVENTIONS:
. Patient tolerated intervention well.

TF

CATH

IV

WOUND

SAFETY:
.

Patient caregiver instructed on
.

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

USED:
.

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.

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.5, 74 form elements, 142 boilerplate words, 35 text areas, 35 checkboxes, 4 conditionals, 205 total clicks
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