visit ASSESS

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"] 
Performed Skilled Nursing visit today

Received patient .

Patient was

Patient Denies

Patient is observed

Head to toe assessment was done:

Patient reports:

Caregiver reports

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 1, 7 form elements, 24 boilerplate words, 7 checkboxes, 169 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: