ROUTINETAKE2

SKILLED NURSING VISIT COMPLETED ON [date name="DATE" default="today"] FOR:[checkbox name="SNVTYPE" value="MEDICATION EDUCATION|MEDICATION PLANNER FILL|DIET EDUCATION|FALL PREVENTION EDUCATION|HOME OXYGEN EDUCATION"][conditional field="SNVTYPE2" condition="(SNVTYPE2).is('CATHETER CHANGE')"] [select name="CATHTYPE" value="FOLEY|SUPRAPUBIC"][/conditional] [checkbox name="SNVTYPE2" value="CATHETER CHANGE|WOUND CARE|PICC LINE DRESSING CHANGE|LAB DRAW|G-TUBE EDUCATION|OSTOMY CARE EDUCATION|" memo="OTHER"][conditional field="SNVTYPE2" condition="(SNVTYPE2).is('')"][text name="variable_1" default="SKILL PROVIDED"][/conditional] AND PHYSICAL ASSESSMENT.

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|AMPUTATION|SOB WITH MINIMAL EXERTION"]AND REQUIRES THE USE OF
[checkbox name="ADUSE" value="NO AD|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]

AT 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 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="BEEN A NEW OCCURANCE|REMAINED UNCHANGED|IMPROVED|WORSENED"] SINCE PRIOR NURSING 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|DULL|THROBBING|TENDER|TIGHT"]. 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|OFFLOADING|REST|DISTRACTION TECHNIQUES"][/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 CONTINUES TO SHOW [select name="COMPLIANCE" value="COMPLIANCE|NON-COMPLIANCE"] WITH TAKING HOME MEDICATIONS AS INSTRUCTED BY 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]
PHYSICAL ASSESSMENT WAS COMPLETED BY WRITER AND DOCUMENTED IN MEDICAL RECORD. [textarea name="ASSESSMENT" default="ENTER ANY ABNORMAL ASSESSMENT INFORMATION OR DELETE IF NO SIGNIFICANT FINDINGS"][conditional field="SNVTYPE2" condition="(SNVTYPE2).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]

AT PREVIOUS NURSING VISIT EDUCATION WAS PROVIDED ON:
[textarea name="PRIOREDUCATION" default="ENTER PREVIOUS EDUCATION PROVIDED"]

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"]
DURING TODAY'S VISIT EDUCATION WAS PROVIDED TO [select name="PTCG" value="PATIENT|PATIENT AND CAREGIVER|PATIENT AND FAMILY|CAREGIVER"] 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.|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 field="SNVTYPE2" condition="(SNVTYPE2).is('PICC LINE DRESSING CHANGE')"] [textarea name="NSKILLPROVIDED" default="PICC LINE DRESSING CHANGE WAS PERFORMED THIS VISIT USING STERILE TECHNIQUE. EXTENSTION TUBING, CONNECTER PORT, AND CAPS CHANGED 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."][/conditional][conditional field="SNVTYPE2" condition="(SNVTYPE2).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="AMOUNT"][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 [select name="LABLOCATIONSITE" value="ST CHARLES HOSPITAL LAB|ST VINCENT HOSPITAL LAB|ST ANNE HOSPITAL LAB|MERCY PERRYSBURG HOSPITAL LAB|ST LUKE HOSPITAL LAB|PROMEDICA TOLEDO HOSPITAL LAB|PROMEDICA BAY PARK HOSPITAL LAB|PROMEDICA FREMONT MEMORIAL HOSPITAL LAB|"] 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 VISIT AND WAS 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.