PLAN

PLAN [checkbox value="MD also ordered to stop patient`s current medication for patient may not tolerate meds by mouth at this time. Instructed daughter that patient may have liquids if patient can tolerate and swallow, to reposition regularly to prevent skin breakdown and to call hospice for any significant changes. |Foley catheter care done, emptied urine bag. |Will continue to keep patient comfortable and free of pain. Will continue to provide supportive care .|All needs attended to. No other concerns at this time|Current pain regimen with opioids and rest has been working well and pain is managed at this point. |Medication reconciliation completed. No discrepancies noted and refills ordered.|PCG is satisfied with care from HA and hospice team|ROM rendered on both upper and lower extremities, tolerated the procedures well| Patient continues with slow decline, with increasing confusion. .|engage in mindfulness/stress reduction techniques (deep breathing, meditation, guided imagery).|plan1|plan2.|Family and hospice team was updated regarding pt`s condition. Med rec done, no discrepancies noted. Pt and pcg has no c/o HA visits. Proper PPE`s in placed during visitation.|Patient`s symptoms are managed by  current plan of care. Medication reconciliation was done, pharmacy notified for refill needed. Medication teaching on medication compliance and symptom management are done with caregiver. PCG verbalized understanding|Covid-19 precautionary measures were observed and followed. Washing hands for at least 20 seconds with soap and water or use of at least 60% alcohol-based sanitizer, wearing a face covering/mask, and social distancing. Patient has no signs and symptoms of Covid-19. Patient did not display any signs of distress during this visit.|plan 3|plan4|plan5|plan6|plan7|plan8|plan9| Provided nursing care with respect and preserved the dignity of the individual.|Encouraged the caregiver to call the 24/7 Hopsice hotline  for any issues/concerns or change of condition."]

PLAN

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 1, 1 form elements, 1 boilerplate words, 1 checkboxes, 24 total clicks
Questions/General site feedback

Send Feedback for this SOAPnote

This site uses Akismet to reduce spam. Learn how your comment data is processed.

More SOAPnotes by this Author: