ROUTINE VISIT 1.0

SKILLED NURSING VISIT COMPLETED ON [date name="DATE" default="today"] FOR: [checkbox name="SNVTYPE" value="PHYSICAL ASSESSMENT|MEDICATION EDUCATION|MEDICATION PLANNER FILL|DIET EDUCATION|FALL PREVENTION EDUCATION|HOME OXYGEN EDUCATION"][conditional field="SNVTYPE" condition="(SNVTYPE).is('CATHETER CHANGE')"][select name="CATHTYPE" value="FOLEY|SUPRAPUBIC"][/conditional][checkbox name="SNVTYPE" value="CATHETER CHANGE|WOUND CARE|PICC LINE DRESSING CHANGE|LAB DRAW|G-TUBE EDUCATION|OSTOMY CARE EDUCATION"]

THIS PATIENT IS [select name="HBSTATUS" value="HOMEBOUND|NOT REQUIRED TO BE HOMEBOUND."][conditional field="HBSTATUS" condition="(HBSTATUS).is('HOMEBOUND')"] DUE TO [checkbox name="TAXING" value="GENERALIZED WEAKNESS|POOR ENDURANCE|PAIN|LIMITED MOBILITY|SOB WITH MINIMAL EXERTION"][/conditional][conditional field="HBSTATUS" condition="(HBSTATUS).is('HOMEBOUND')"] AND REQUIRES THE USE OF [checkbox name="ADUSE" value="CANE|WALKER|MANUAL WHEELCHAIR|MOTORIZED WHEELCHAIR|MECHANICAL LIFT AND WHEELCHAIR|SUPPLEMENTAL OXYGEN"] AND [checkbox name="ADLNEED" value="STANDBY ASSIST X1 TO LEAVE HOME SAFELY.|MAXIMUM ASSISTANCE TO LEAVE HOME SAFELY."][/conditional]

DURING THIS VISIT PATIENT WAS [select name="AXO" value="ALERT AND ORIENTED X4|ALERT BUT DISORIENTED TO"][conditional field="AXO" condition="(AXO).is('ALERT BUT DISORIENTED TO')"] [checkbox name="ORIENTATIONSTATUS" value="TO SELF|TIME|PLACE|SITUATION"] 
ORIENTATION LEVEL IS  [select name="CHANGE" value="CHANGED|UNCHANGED"] FROM PATIENT'S BASELINE COGNITIVE STATUS. [/conditional]
[select name="VITALS" value="VITAL SIGNS WNL|ABNORMAL VITAL SIGN FINDINGS NOTED:"][conditional field="VITALS" condition="(VITALS).is('VITAL SIGNS WNL')"] WITH NO ACUTE DISTRESS NOTED.[/conditional] [conditional field="VITALS" condition="(VITALS).is('ABNORMAL VITAL SIGN FINDINGS NOTED:')"] [text name="variable_1" default="Enter"]. PHYSICIAN WAS NOTIFIED VIA [select name="notifiedby" value="E-FAX|PHONE CALL"].[/conditional]
PATIENT REPORTED [select name="FALLS" value="NO FALLS|1 FALL WITHOUT INJURY|1 FALL WITH INJURY|MULTIPLE FALLS WITHOUT INJURY|MULTIPLE FALLS WITH INJURY"] SINCE LAST NURSING VISIT.
[conditional field="FALLS" condition="(FALLS).is('1 FALL WITHOUT INJURY')||(FALLS).is('1 FALL WITH INJURY')||(FALLS).is('MULTIPLE FALLS WITHOUT INJURY')||(FALLS).is('MULTIPLE FALLS WITH INJURY')"]WRITER EDUCATED PATIENT ON FALL PREVENTION INCLUDING [checkbox name="FALLEDU" value="USING ASSISTIVE DEVICES|REMOVING THROW RUGS|REMOVING EXCESS CLUTTER|CREATING CLEAR PATHWAYS|HAVING ADEQUATE LIGHTING THROUGHOUT THE HOME|CHANGING POSITION SLOWLY"] PATIENT [select name="TEACHINGRESULTS" value="VERBALIZED UNDERSTANDING.|VERBALIZED UNDERSTANDING AND WAS ABLE TO TEACH BACK.|VERBALIZED UNDERSTANDING BUT UNABLE TO TEACH BACK."] [/conditional]

PATIENT REPORTED EXPERIENCING[select name="PAINTYPE" value="NO CURRENT PAIN.|ACUTE PAIN|CHRONIC PAIN"][conditional field="PAINTYPE" condition="(PAINTYPE).is('ACUTE PAIN')||(PAINTYPE).is('CHRONIC PAIN')"] IN: [text name="AREAOFPAIN" default="PAIN LOCATION"]. 
PATIENT STATED THAT PAIN HAS [select name="PAINST" value="REMAINED UNCHANGED|IMPROVED|WORSENED"] SINCE PRIOR VISIT. PATIENT RATED PAIN AT [text name="PAINSCALE" default="0"] ON 0-10 SCALE. PATIENT DESCRIBES PAIN AS: [checkbox name="PAINDESC" value="ACHING|BURNING|SHARP|THROBBING|TENDER"]PATIENT STATED THAT PAIN HAS BEEN [select name="PAINTOL" value="SOMEWHAT TOLERABLE|MOSTLY TOLERABLE|UNRELIEVED"] WITH CURRENT TREATMENT OF: [checkbox name="PNRELIEF" value="ORAL MEDICATION|HEAT|ICE|POSITIONAL CHANGES|REST"][/conditional]
[conditional field="PAINST" condition="(PAINST).is('WORSENED')"]PHYSICIAN WAS NOTIFIED VIA [select name="notifiedby" value="E-FAX|PHONE CALL"] REGARDING PATIENT'S COMPLAINTS OF UNRELIEVED PAIN.[/conditional]
PATIENT REMAINS [select name="COMPLIANCE" value="COMPLIANT|NON-COMPLIANT"] WITH TAKING HOME MEDICATIONS AS INSTRUCTED PER PHYSICIAN. [conditional field="COMPLIANCE" condition="(COMPLIANCE).is('NON-COMPLIANT')"] PHYSICIAN AND SUPERVISIOR NOTIFIED OF MEDICATION NON-COMPLIANCE. [/conditional]PATIENT [select name="YESNOMEDS" value="DENIED ANY RECENT|REPORTED NEW"] MEDICATION CHANGES SINCE LAST NURSING VISIT. [conditional field="YESNOMEDS" condition="(YESNOMEDS).is('REPORTED NEW')"] MEDICATION PROFILE UPDATED.[/conditional]
SKILLED NURSING ASSESSMENT COMPLETED BY WRITER AND DOCUMENTED IN MEDICAL RECORD WITH ABNORMAL FINDINGS OF:[textarea name="ASSESSMENT" default="ENTER ANY ABNORMAL ASSESSMENT INFORMATION"]
[conditional field="SNVTYPE" condition="(SNVTYPE).is('MEDICATION EDUCATION')||(SNVTYPE).is('DIET EDUCATION')||(SNVTYPE).is('FALL PREVENTION EDUCATION')||(SNVTYPE).is('HOME OXYGEN EDUCATION')||(SNVTYPE).is('G-TUBE EDUCATION')||(SNVTYPE).is('OSTOMY CARE EDUCATION')"] AT PREVIOUS NURSING VISIT EDUCATION WAS PROVIDED ON:[/conditional]
[conditional field="SNVTYPE" condition="(SNVTYPE).is('MEDICATION EDUCATION')||(SNVTYPE).is('DIET EDUCATION')||(SNVTYPE).is('FALL PREVENTION EDUCATION')||(SNVTYPE).is('HOME OXYGEN EDUCATION')||(SNVTYPE).is('G-TUBE EDUCATION')||(SNVTYPE).is('OSTOMY CARE EDUCATION')"][textarea name="PRIOREDUCATION" default="ENTER PREVIOUS EDUCATION PROVIDED"][/conditional] 
PATIENT IS DEMONSTRATING [select name="PROGRESS" value="POOR|FAIR|GOOD"] PROGRESS TOWARD MEETING NURSING GOALS AS EVIDENCED BY: [textarea name="GOALSREPORT" default="ENTER ANY CHANGES HAS PATIENT MADE TO IMPROVE OR WORSEN HEALTH CONDITIONS"]
[conditional field="SNVTYPE" condition="(SNVTYPE).is('WOUND CARE')"]
WOUND CARE PROVIDED THIS VISIT:
[textarea name="WOUNDCAREVISIT" fillable="true" default="WOUND CARE WAS PROVIDED AS ORDERED TO ***LOCATION*** ***ENTER WOUND CARE PERFORMED***"]
[select name="WCTOL" value="PATIENT TOLERATED WOUND CARE WITH NO COMPLAINTS OF PAIN OR DISCOMFORT DURING DRESSING CHANGE.|PATIENT TOLERATED WOUND CARE WITH MINIMAL COMPLAINTS OF PAIN OR DISCOMFORT DURING DRESSING CHANGE.|PATIENT REFUSED WOUND CARE THIS VISIT."][/conditional]
[conditional field="SNVTYPE" condition="(SNVTYPE).is('MEDICATION EDUCATION')||(SNVTYPE).is('DIET EDUCATION')||(SNVTYPE).is('FALL PREVENTION EDUCATION')||(SNVTYPE).is('HOME OXYGEN EDUCATION')||(SNVTYPE).is('G-TUBE EDUCATION')||(SNVTYPE).is('OSTOMY CARE EDUCATION')"] DURING TODAY'S VISIT EDUCATION WAS PROVIDED BY WRITER TO [select name="PTCG" value="PATIENT|PATIENT AND CAREGIVER|PATIENT AND FAMILY|CAREGIVER|PATIENT"] ON [textarea name="EDUCATIONSNV" default="ENTER ALL EDUCATION PROVIDED"][select name="TEACHINGRESULT" value=" PATIENT VERBALIZED UNDERSTANDING AND WAS ABLE TO TEACH BACK.|PATIENT VERBALIZED UNDERSTANDING AND WAS ABLE TO RETURN DEMONSTRATE TEACHING.|PATIENT VERBALIZED UNDERSTANDING BUT UNABLE TO TEACH BACK.|PATIENT VERBALIZED UNDERSTANDING BUT UNABLE TO DEMONSTRATE.|CAREGIVER VERBALIZED UNDERSTANDING AND WAS ABLE TO TEACH BACK.|CAREGIVER VERBALIZED UNDERSTANDING BUT WAS UNABLE ABLE TO TEACH BACK.|CAREGIVER VERBALIZED UNDERSTANDING AND WAS ABLE TO RETURN DEMONSTRATE.|CAREGIVER VERBALIZED UNDERSTANDING BUT WAS UNABLE TO RETURN DEMONSTRATE.|BOTH VERBALIZED UNDERSTANDING.|BOTH VERBALIZED UNDERSTANDING AND WERE ABLE TO TEACH BACK.|BOTH VERBALIZED UNDERSTANDING AND WERE ABLE TO DEMONSTRATE.|BOTH VERBALIZED UNDERSTANDING BUT WERE UNABLE TO DEMONSTRATE."][/conditional][conditional field="SNVTYPE" condition="(SNVTYPE).is('PICC LINE DRESSING CHANGE')||(SNVTYPE).is('FOLEY CATHETER CHANGE')"] [textarea name="NSKILLPROVIDED" default="ENTER SKILLED SERVICE PROVIDED THIS VISIT"] [select name="WCTOL" value="PATIENT TOLERATED PROCEDURE WITH NO COMPLAINTS OF PAIN OR DISCOMFORT.|PATIENT TOLERATED PROCEDURE WITH MINIMAL COMPLAINTS OF PAIN OR DISCOMFORT.|PATIENT REFUSED."][/conditional][conditional field="SNVTYPE" condition="(SNVTYPE).is('LAB DRAW')"] ORDERED LAB WAS [select name="LABYESNO" value="UNABLE TO BE OBTAINED|OBTAINED"] THIS VISIT.[/conditional][conditional field="LABYESNO" condition="(LABYESNO).is('OBTAINED')"] VIA[select name="LABDRAWLOC" value="SELECT|VENIPUNCTURE|PICC LINE|MID-LINE|PORT|URINE SAMPLE|STOOL SAMPLE"][/conditional][conditional field="LABDRAWLOC" condition="(LABDRAWLOC).is('VENIPUNCTURE')||(LABDRAWLOC).is('PORT')"] AND [select name="LABATTEMPTDRAW" value="ONE|TWO|THREE|FOUR"] ATTEMPT TO PATIENT'S [text name="LABLOCATIONSITE" default="LOCATION"][/conditional][conditional field="LABYESNO" condition="(LABYESNO).is('OBTAINED')"] AND TRANSFERRED INTO [text name="numba" default="ONE"][checkbox name="tube color" value="GREEN TUBE|PURPLE TUBE|GOLD TUBE|RED TUBE|SPECIMEN CUP"][/conditional][conditional field="LABYESNO" condition="(LABYESNO).is('OBTAINED')"]LABS WORK WAS LABELLED IN FRONT OF PATIENT AND LABS WILL BE TRANSFERRED TO [text name="LABLOCATIONSITE" default="DROP OFF LOCATION"] WITH RESULTS TO BE FAXED TO [text name="faxx" default="NAME"].[/conditional]
PATIENT VISIT CALENDAR REVIEWED AND PATIENT NOTIFIED OF NEXT SKILLED NURSING VISIT SCHEDULE ON: [select name="DAYS" value="MONDAY|TUESDAY|WEDNESDAY|THURSDAY|FRIDAY|SATURDAY|SUNDAY"] FOR [checkbox name="NEXTVISIT" value="SKILLED NURSING ASSESSMENT|CONTINUED MEDICATION EDUCATION|MEDICATION PLANNER FILL|CONTINUING DIET EDUCATION|FALL PREVENTION EDUCATION|HOME OXYGEN EDUCATION|CONTINUED WOUND ASSESSMENT AND WOUND CARE|FOLEY CATHETER EDUCATION|FOLEY CATHETER CHANGE|PICC LINE DRESSING CHANGE|LAB DRAW|G-TUBE EDUCATION|OSTOMY CARE EDUCATION"]
PATIENT STATED NO QUESTIONS OR CONCERNS AT END OF TODAY'S VISIT. PATIENT ENCOURAGED TO CONTACT OL OFFICE WITH ANY QUESTIONS OR CONCERNS.
PATIENT WAS INSTRUCTED WHEN TO CONTACT HOME HEALTH AGENCY AND/OR PCP VS. 911 FOR EMERGENCY NEEDS.





SKILLED NURSING VISIT COMPLETED ON FOR:

THIS PATIENT IS

DURING THIS VISIT PATIENT WAS

PATIENT REPORTED SINCE LAST NURSING VISIT.


PATIENT REPORTED EXPERIENCING

PATIENT REMAINS WITH TAKING HOME MEDICATIONS AS INSTRUCTED PER PHYSICIAN. PATIENT MEDICATION CHANGES SINCE LAST NURSING VISIT.
SKILLED NURSING ASSESSMENT COMPLETED BY WRITER AND DOCUMENTED IN MEDICAL RECORD WITH ABNORMAL FINDINGS OF:


PATIENT IS DEMONSTRATING PROGRESS TOWARD MEETING NURSING GOALS AS EVIDENCED BY:


PATIENT VISIT CALENDAR REVIEWED AND PATIENT NOTIFIED OF NEXT SKILLED NURSING VISIT SCHEDULE ON: FOR
PATIENT STATED NO QUESTIONS OR CONCERNS AT END OF TODAY'S VISIT. PATIENT ENCOURAGED TO CONTACT OL OFFICE WITH ANY QUESTIONS OR CONCERNS.
PATIENT WAS INSTRUCTED WHEN TO CONTACT HOME HEALTH AGENCY AND/OR PCP VS. 911 FOR EMERGENCY NEEDS.





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Sandbox Metrics: Structured Data Index 0.73, 69 form elements, 119 boilerplate words, 7 text boxes, 6 text areas, 1 dates, 11 checkboxes, 23 drop downs, 21 conditionals, 100 total clicks
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