visit notes

Performed Skilled Nursing visit today

Received patient [checkbox value="in bed|at the dayroom |Dining area|asleep|easily aroused|non responsive|responds to sound|responds to touch|respond so pain|awake|alert and oriented to|person|time|palce|situation|self only|in no apparent distress|patient is on continous oxygen at 2LPM via NC stating at |p3|p4|p5|p6|p7|p8"].

 Patient was [checkbox value="calm|cooperative|uncooperative with assessment|minimally cooperative with assessment|blunt|lethargic|fair grooming and hygiene|confused|anxious|agitated|pleasantly confused|forgetful|bright affect|cachectic|frail|debilitated|able to follow command|needs a lot of prompting|able to verbalize needs|unable to follow command|unable to verbalize needs|bedbound|No reported of agitation or aggression. Minimal speech to non verbal today. |Patient continues to discuss childhood or younger year memories but has difficulty with short term memories not remembering what he ate for breakfast or recent events throughout the week."]  
 
Patient Denies [checkbox value="chest pain,|shortness of breath,|pain|coughing|denie1|denies2|denies3"] 

Patient is observed [checkbox value="short of breath with minimal exertion,|shortness of breath with transfer,|short of breath with repositioning|pursed lips|short fo breath with speech|no apparent injury|No sign of pain or discomfort."]

Head to toe assessment was done: [checkbox value="Pupils equal, round and reactive to light|Patient has poor eye contact|eyes are closed|eyes are open but non reactive|able to follow object|poor visual tracking|Apical pulse normal rate and rhytym|Apical pulse aryhtmic|apical pulse weak|Radial pulse equal +1|pedal pulses weak|peal pulses absent|tachychardic|tachypneic|respiration regular and unlabored|labored breathing|cheyne stokes|Accessory muscles being used.|Radial pulse equal and palpable, |Pedal pulses equal and palpable|no edema|Bilateral Lower extrmities with non-pitting edema|left lower extremity xx   edema|right lower extremnity   xx edema|weeping edema|Skin is dry |Skin is moist|warm|cool|intact|Lungs clear to auscultation|no adventitious sound|Left lower lobe with fine crackles|right lower lobe with fine crackles|wheezing|diminished|upper lobes clear to auscultation|Abdomen|soft|firm|non-tender|tender on left lower quadrant|bowel sound heard on all quadrants|cathether is patent|no limitations on range of motion from baseline|xxx mild contraction|severley contracted|modertaley contracted|Trace edema noted in bilateral lower extremities. Legs elevated on recliner and educated GH caregivers on elevation to help with swelling. |tremors noted|assessment1|assessment2|assessment4|assessment5|assessment6|assessment7"]

Patient reports:[checkbox value="difficulty falling asleep |staying asleep|movingh bowel|walking|feeling weak|feeling tired|feeling hopeless|feeling sad|feeling ok|no interest in doing things|poor appetite|poor sleep quality|complaints of|PAIN at location PQRST|pain is controlled by current medication|Hospice Medical Director was infomed, medication adjsutment was ordered|assess1|asses2|asses3"]

Caregiver reports [checkbox value="poor appetite|consumes less than 40percent of meals served|consumes less than 30percent of meals served|consumes less than 20percent of meals served|consumes less than 10percent of meals served|Denies choking or problem swallowing. Noted increased confusion|sleeps almost 15 houra a day|sleeps almost 20 houra a day| does not sleep at night but take daytime naps|is agitated at night|has episodes of aggression| has difficulty moving bowel|is constiapated|has hard stool|patient needs  a lot of prompting and enxouraging  when eating |uanble to feed self|Able to feed self but needs prompting at times|increasing wekness|increasing coinfusion|increasing needs for assistance with mobility|transfer|toileting|bathing|dressing|feeding|ppetite apparently continuous to decreased, frequently declined to eat. | Pcg was instructed to give Ensure everyday for her supplement nutrition|caregiver1|CG2|Cg3|CG4|cg5"] 
Provided education [checkbox value="Provided education  disease process and symptoim management |Instructed PCG to clean wound with NS/wound cleanser,apply Medhoney and cover with protective dressing 2x/wk and prn as ordered|educationprovided  to PCG on fall safety and Precaution|dvised PCG to elevate and offload heels with pillows while in bed to decrease swelling and turn to sides to prevent skin breakdown|Advised med techs and caregivers to frequently offer patient fluids and ensure to prevent dehydration and constipation| Instructed PCG with Aspiration Safety|Pain management and importance of timely medication administartion|RN provided safety instructions, physical comfort, structural and emotional support during the visit. RN gave teachings regarding wound care and showed PCG the proper application of topical medication. PCG agrees with plan of care. |Fall risk education and oxygen safety education  provided to Caregiver and patient verbalize understanding|SN educated the patient and caregiver on how to operate the oxygen, medication teaching done.|Advised pt to call for help when getting up and always use her walker for safety to prevent fall-verbalized understandin|current treatment is effective|Reinforced safety teachings, aspiration precautions, fall preventive measures, infection control and covid 19 awareness.|teachback satisfactory.|Cargeiver and Patient verblaized understanding|Advised caregiver to notify Hospice ASAP with fall incidents and any significant changes-verbalized understanding and appreciated service|Caregiver was provided safety teachings, fall preventive measures, aspiration precautions, infection control and Covid 19 awareness and advised to notify Hospice team for any concern|educate1|educate2|intervention1|intervention2|intervention3|request1|request2|request3|Left patient safe and comfortable"]

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."]
VITALS SIGNS: 
BP  
Pulse:
Respiration unlabored at XXXbpm
Temp XXF
Oxygent saturation at    in   [select name="oxygenation needs" value="room air|continous oxygen|2LPM via NC"] 
LMAC: xxcm


Recommendations of Frequency: [select name="scheduling" value="Weekly|Bi-weekly|Monthly||Next appointment to be scheduled by the guardian|The next appointment to be scheduled by the Client"].
The next appointment is scheduled for [date name="variable_1" default="today"]
XURBANO[date name="VISIT" default="today"]
Performed Skilled Nursing visit today

Received patient .

Patient was

Patient Denies

Patient is observed

Head to toe assessment was done:

Patient reports:

Caregiver reports
Provided education

PLAN
VITALS SIGNS:
BP
Pulse:
Respiration unlabored at XXXbpm
Temp XXF
Oxygent saturation at in
LMAC: xxcm


Recommendations of Frequency: .
The next appointment is scheduled for
XURBANO

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