COMPREHENSIVE ADULT SOC ASSESSMENTWITH CMS 485 (POC) INFORMATION

/DATE

TIME OUTTIME IN(M0030) Start of Care Date:

Provider Number:

Emergency/Disaster Plan Classification Code:

PATIENT NAME - Last, First, Middle Initial Med. Record #

www.pnsystem.com 305.777.5580 SOC ADULT ASSESSMENTPage 1 of 8

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yearmonth day

/ /

Agency Name:________________________________________

Employee's Name/Title Completing the Assessment:

_____________________________________________________________

Physician name: _______________________________

Address: ___________________________ _________________________________________

Phone Number: ______________________________

24

Other Physician (if any): _______________________________

Address: ___________________________ _________________________________________

Phone Number: ______________________________

Patient ID Number: __ __ __ __ __ __ __ __ __ __ __ __ __ __ (Medical Record)

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2

Patient Name:____________________________________________...Address: _____________________________________________________.. _____________________________________________________

..Patient Phone: __________________________

Social Security Number:_________________

Medicaid Number: __ __ __ __ __ __ __ __ __ __ __ __ __ __

Birth Date: __ __ /__ __ /__ __ __ __ Gender: Male Female month / day / year

6

Certification Period:From __/___/ To / / /

3

1

19EMERGENCY CONTACT:

Address:Phone: Relationship:OTHER:

6REFERRAL SOURCE (if not from Primary Physician):

Phone:

Evacuation Form needed? Emergency Registration Completed (please document)

Fax:

PHYSICIAN: Date last contacted: Date last visited: Reason:

Phone:

7

ALF / AFHC (circle)

Name:

Phone:

PT ID PERFORMED VIA NAME, DOB, FACE RECOGNITION AND ADDRESS BEFORE SERVICE PROVIDED

POC (CMS - 485) Box#

SG Safety Goal

/ / / /

SG

Referral date: / /N/A

CHIEF COMPLAINT:

PRESENT ILLNESS/DIAGNOSIS:

NoRECENT HOSPITALIZATION? Yes, datesReason:

Yes, specifyNoNew diagnosis/condition?

PERTINENT HISTORY AND/OR PREVIOUS OUTCOMES:

Fractures: _______OsteoporosisRespiratoryCardiacHypertension

InfectionOpen WoundImmunosuppressed

Cancer (site: )

Other:Surgeries:

-

Up-to-dateIMMUNIZATIONS:Tetanus Other (specify)Needs: Influenza PneumoniaH1N1

ICD-10-CM Primary & Other Diagnosis

Date //)(

Date / /)(

1212

Date //)(

Date / /)(

Date //)(

Date / /)(ICD-10-CM Surgical Procedure

Date //)(

Date / /)(

1212

PREVIOUS OUTCOMES:

DiabetesInsulin DependentNon Insulin Dependent

DIAGNOSIS:

VITAL SIGNS: Blood Pressure: Sitting/lying RLStanding R

LOral Axillary

Temperature:

Rectal Tympanic

Rest ActivityCheynes Stokes

Death rattleRespirations:

Apnea periods -sec.Accessory muscles usedRegular Irregular

Regular Irregular

Pulse: BrachialApicalRadial Carotid

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CARDIOVASCULAR

SYSTEM REVIEWLocalizedPostural SubsternalChest pain: Anginal

Vise-like Dull AcheSharpRadiatingAssociated with: ActivitySOB Sweats

Glaucoma JaundiceGlasses Frequency/durationContacts: R / L PtosisBlurred vision Other (specify)Prosthesis: R / L Legally blind Palpitations: Nocturnal/Persistent/intermittent

EYES Infections Other (specify)DateCataract surgery: Site / / Heart rate: Regular Irregular Reg./Irreg.

Other (specify, incl. hx) Orthostatic hypotension Syncope VertigoNO PROBLEM BP (specify)Reg. Irreg. (specify)Heart sounds:Deaf: R / L Hearing aid: R/LHOH: R / L

Pulse deficit (specify)

EAR

S TinnitusVertigo Dependent:Edema: Pedal R/LOther (specify, incl. hx) Non-pitting (site)Pitting +1/+2/+3/+4NO PROBLEMClaudication: R calf/L calf/Night changes

HEAD/NECK JVD FatigueHeadache( see Neurological section)

RxThrombus: SiteInjuries/Wounds ( see Skin Condition/Wound section)Cramps: LE/UE/Night (site)Masses/Nodes: Site SizeCyanosis (site)AlopeciaCap refill: 3 sec.Other (specify, incl. hx)Pulses: LDP/LPT/RDP/RPTNO PROBLEMPacemaker: Date Type/ /NOSE/THROAT/MOUTH Other (specify incl. hx)

HoarsenessCongestion Epistaxis DysphagiaLesions Sore throatSinus prob.Loss of smell

NO

SE Other (specify, incl. hx)Other (specify, incl. hx)

NO PROBLEMRESPIRATORY STATUSClear Crackles Wheeze AbsentBreath sounds:NO PROBLEMNO PROBLEM

Cough: Dry/Acute/ChronicDentures: Upper /Lower /Partial Masses/Tumors Productive: Thick/Thin/Difficult Color

MO

UTH Ulcerations ToothacheGingivitis Smoker: packs/day X years

Other (specify, incl. hx)Exertion: amb. feetRestDyspnea:

during ADLsNO PROBLEMOrthopnea: # of pillows

ENDOCRINE Fremitus: LocationCrepitus/Amt.Hemoptysis: FrequencyIntolerance to heat/coldEnlarged thyroid Fatigue

Barrel chestDiabetes: Type I/Type II Onset / / Skin temp/color changemos. yearsDiet/Oral control X

Percussion: Resonant/Tympanic/Dull

Med./dose/freq.Ant.R Lat. Post.Chart lobe: L;

Insulin/dose/freq.Hyperglycemia: Glycosuria / Polyuria / Polydipsia 02 Sat.Hypoglycemia: Sweats/Polyphagia/Weak/Faint/Stupor Mask Nasal Trach02 use: L/rnin. byBlood Sugar RangeSelf-care/Self-observational tasks (specify)

ConcentratorLiquidGas

Other (specify, incl. hx)Other (specify, incl. hx)

NO PROBLEMNO PROBLEM

Med. Record #PATIENT/CLIENT NAME - Last, First, Middle Initial

Page 2 of 8

NO

SE

MO

UT

HE

AR

SV

ISIO

N

THR

OA

T

CARDIOVASCULAR STATUS

8

www.pnsystem.com 305.777.5580 ADULT SOC ASSESSMENT

COMPREHENSIVE ADULT SOC ASSESSMENTWITH CMS 485 (POC) INFORMATION

Oxygen Precaution/Fire Prevention followed/explained to patient SG

5-Excellent3-Fair 4 Good1- Poor 2- Guarded

PROGNOSIS: 20

Nose surgery:

Any mouth surgery/procedure:

FUNCTIONAL LIMITATIONS7-Ambulation1 -Amputation

2-Bowel/Bladder 8-Speech(incontinence)9-Legally blind3 - Contracture

A -Dyspnea with 4-Hearing

B- Other (specify)

5-Paralysis 6-Endurance

18A

Dizziness

Generalized WeaknessArthralgia

InsomniaHeadache

AnxietySOB on exertion

Heartburn

Poor vision

Productive cough

Unsteady GaitPain on ambulation

Varicositis on lower ext.Edema in __________

Legs weak

Chest pain on exertionFatigues at times

Decreased Bil. breath soundsBack Pain

PalpitationsLimited MobilityLimited ROMLeg crampsFreq. Coughing episodesNeeds assistance of 1 person

HOMEBOUND REASON:

Needs assistance for all activities (ADL's)

Requires assistance to ambulate/Decreased Range of MotionGeneralized Weakness

Confusion, unable to go out of home alone

Severe SOB, SOB upon exertion, amb. ____ feet

Unable to safely leave home without assistance

Medical restrictions

Dependent upon adaptive device(s)

(Mark all that apply):

Other (specify):

Needs assist of 1-2 persons

Bedbound (Partial/Complete)

Mobility/Ambulatory device(s) used:

Unsteady Gait

18A

GENITOURINARY STATUS

(Check all that apply:) Nocturia xUrgency/frequencyBurning/pain Hesitancy Hematuria Oliguria/anuriaIncontinence: Urinary Bowel Diapers/other:

Blood-tingedColor: Yellow/straw Amber Brown/gray Other: Clarity: Clear Cloudy Sediment/mucousOdor: Yes No Urinary Catheter: Type Last changed on: Foley inserted (date) with FrenchInflated balloon with mL without difficulty Suprapubic Irrigation solution: Type (specify): Amount mL Frequency ReturnsPatient tolerated procedure well Yes No Urostomy (describe skin around stoma):

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NUTRITIONAL STATUS

GENITALIADischarge/Drainage: Urine/Vag. mucus/FecesLesions/Blisters/Masses/Cysts Inflammation

Surgical alteration

NUTRITION HEALTH SCREEN

Prostate problem: BPH/TURP Date / /

Directions: Circle each area with ''yes'' to assessment, then total score

Self-testicular exam Freq.

to determine additional risk. YESHas an illness or condition that changed the kind and/or amount offood eaten. 2Eats fewer than 2 meals per day. 3Eats few fruits, vegetables or milk products. 2Has 3 or more drinks of beer, liquor or wine almost every day. 2Has tooth or mouth problems that make it hard to eat. 2Does not always have enough money to buy the food needed. 4Eats alone most of the time. 1Takes 3 or more different prescribed or over-the-counter drugs a day. 1Without wanting to, has lost or gained 1 0 pounds in the last 6 months. 2Not always physically able to shop, cook and/or feed self. 2

TOTAL

Menopause: DateHysterectomy / /Date last PAP Results/ /

Breast self-exam. freq. Discharge: R/LMastectomy: R/L Date / /Other (specify incl. hx)

NO PROBLEM

HEMATOLOGY/ IMMUNEAnemia: Iron deficient/Pernicious Secondary Bleed: GI/GU/GYN/Unknown

Ablastic/Hemolytic/PolycythemiasThrombocytopenia Coagulation disordersHemophilia, other

INTERPRETATION

Malignancies (specify):

0-2 Good. As appropriate reassess and/or provide information based on situation.3-5 Moderate risk. Educate, refer, monitor and reevaluate based on patient

Prior RxComplications

situation and organization policy.

Other (specify, immunological problem)

6 or > High risk. Coordinate with physician, dietitian, social service professionalor nurse about how to improve nutritional health. Reassess nutritional status andeducate based on plan of care.

NO PROBLEM

NEUROLOGICALOriented X

NO PROBLEMReprinted with permission by the Nutrition Screening Initiative, a project of the American Academy ofFamily Physicians, the American Dietetic Association and the National Council on the Aging, Inc., andfunded in part by a grant from Ross products Division, Abbott Laboratories Inc.

Insomnia/Change in sleep patternSlurred speech

ELIMINATION STATUS

SyncopeVertigoSensory lossAtaxia

Usual frequencyLast BM / /

NumbnessHx of frequent falls

>3x/day

Page 4 of 8 www.pnsystem.com 305.777.5580 ADULT SOC ASSESSMENT

SAFETY MEASURES

Origin:

OnsetLocation

Quality (i.e., burning, dull ache)Intensity level: 0 1 2 3 4 5 6 7 8 9 10Freq./Duration

Aggravating/Relieving Factors:

Pain Management History

SKIN CONDITION/WOUNDS/LESION

Present Pain Management Regimen

Effectiveness

Sutures Staples

Turgor: Good Poor

Other (specify)

NO PROBLEM

Edema: Lymph Hema.Other (specify, incl. pertinent hx)

APPLIANCES/AIDS/SPECIAL EQUIPMENT:Wheelchair

Cane WalkerCrutch(es)

NO PROBLEM

Other (specify):

Denote location of specific skin conditions/wounds by numberingappropriately on illustrations below.

Prosthesis: Hospital bed

Oxygen: HME Co.

Phone:

Fire Alarm Smoke Alarm

Size (cm)Depth

MUSCULOSKELETALFracture (location)Swollen, painful joints (specify)

LocationContractures: JointPoor conditioningAtrophyParesthesiaDecreased ROM

Shuffling/Wide-based gait WeaknessAmputation: BK/AK/UE; R/L (specify)

QuadriplegiaParaplegiaHemiplegiaOther (specify, incl. pertinent hx)

Med. Record #PATIENT/CLIENT NAME - Last, First, Middle Initial

#ICONDITION #2 #3 #4

Safety Measures: CMS485 (POC)Cast PrecautionsChange position slowlyCoumadin/Heparin PrecautionsDo not lift, bend, stoopGood handwashing techniqueOxygen Precaution/Fire preventionPractice Universal Precautions

15

Safe Ambulation

Respiratory PrecautionsDiabetic PrecautionsWound/Decubitus precautionsAdequate lightingPrevent Cardiac OverloadPrevent Falls and Injuries G.I. Precautions

Prev. Infection ComplicationsSeizure PrecautionsSuicide precautionsSupport due functional limitationTeach coping skillsSafe storage/disposal syringes Cardiac Precautions

G.U. Precautions

Safe TransfersSAN PrecautionsCatheter CareProvide Emotional SupportEmergency Plan

Maintain Safe/clear EnvironmentMaintain Good Skin care

Clear pathways

Other:

SG

Correct handwashing technique SGCheck bathroom, floor/stairs for safety hazards

SG

PAIN MANAGEMENTItch Rash Dry Scaling Incision Wounds LesionsDecubitus Fistulas Abrasions LacerationsBruises Ecchymosis Pallor: Jaundice Redness

Stage

Drainage/Amt.

TunnelingOdor

Sur. Tis.Edema

Stoma

None known / NKA AspirinSulfaPollens and mold spores

EggsPenicillin

Insect bitesDairy/Milk products

Other

17

Iodine Dust mitesAnimal dander and urine

ALLERGIES

Lifts Bedside Commode

Patient is prone to FALL: Yes:NoFall risk assessment conducted every_______________Fall prevention program in place, patient instructed SG

Comment:

HOME ENVIRONMENT SAFETYSafety hazards in the home: (check all that apply)

NYFire alarm/smoke detector /Fire extinguishInadequate heating/ cooling/ electricity / lightingHurricane, Disaster Emergency supplies/kits

NYY N

NYFirst aid box/Emergency Equipment or SuppliesNYUnsafe gas/electrical appliances or electrical outletsNYInadequate running water, plumbing problemsNUnsafe storage of supplies/ equipment/ HME

No telephone available and/or unable to use the phonePest problems, Insects/rodentsMedications stored safely, clearly-easy use

NYNYNY

Emergency planning, Exit Plan in place, more than one exit Y NNYEnough Ventilation

Safe Beds/Chairs, clear pathwaysY NAble to follow directions in case of Emergency

NYSlippery Floors, Ashtrays (if a smoker)NYPlan for power failure, emergency lights, flashlights, etc.

Y

NY

NYRelevant medical appliances, if applicable ( wheelchair, O2, Monitors, etc.)NYHurricane Shutter , Disaster Plan

ENTERAL FEEDINGS - ACCESS DEVICE - IVNasogastric Gastrostomy Jejunostomy Feeding type:

Pump: (type/specify) Bolus Continuous

TPNDevice: IV:

N/AFinancial ability to pay for medications/insurance covered: Yes NoComment:

SG

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PN SystemPainFaces

PATIENT CARE COORDINATIONCARE PLAN: Reviewed with patient involvement

Order obtainedMedication Form completed/reviewed/updated No changeMEDICATION RECORD:Ineffective drug therapy

Significant drug interactionsSignificant side effects

Non-compliance with drug orders Duplicate drug therapy

Other (specify):MSWSNPhysician AidePT OT STCARE COORDINATION:

Explain:

DME SUPPLIES

IV start kit Underpads, size: BathbenchChemstrips2x2'sIV pole

External catheters

Syringes Cane Quad CaneIV tubing

Urinary bag/pouch

COTTON TIP APP4x4's

CommodeAlcohol swabs

Ostomy pouch (brand, size)

Special mattress overlayABD's

Angiocatheter size

Cotton tipped applicatorsPeroxide Ostomy wafer (brand, size)

Pressure relieving device

Wound cleanserExtension tubingsWound gel

Injection caps

Stoma adhesive tape

Eggcrate

Drain sponges Central line dressing

Skin protectant

Hospital bed

Gloves:Non-sterile

Side Rails

Infusion pump Hoyer lift

Sterile Batteries size Enteral feeding pump

Hydrocolloids

Enema suppliesSyringes size

Nebulizer

Kerlix size

Feeding tube:Nu-gauze

MEFIX 2X11 YD (EA)

Oxygen concentrator

sizetype Suction machine

Saline/NSS

FOLEY/CATH SUPPLIES:

Suture removal kit Ventilator

Tape

Fr catheter kit

Staple removal kit Walker

(tray, bag, foley)Transparent dressings

Steri strips

Straight catheter

Wheelchair

Ointment

TRIPLE ANTIBIOTIC 30GR

Irrigation tray

Tens unitSaline/NSS

OtherAcetic acid

Other

10

14

PATIENT OTHER EVALUATIONSCheck all that applies:Patient/caregiver(CG) independent with:

Trach care:

NoYesWound/Decubitus care:

Yes No

Yes No

Ostomy care: Yes

NoYesDiabetic management/care:

No

NoYesNoYesInsulin administration: NoYes

Oxygen use/precautions maintained, fire prevention:

Yes NoGlucometer use/calibration:

Use of home medical equipment / devices:

NoYesNutritional management/Diet:

NoCaregiver/Family member present during the visit: Yes

NoYesPatient/CG able to understand instructions/teaching:

Does the patient/CG have a plan when disease symptoms exacerbate(e.g., when to call the nurse / Agency vs. emergency 911): NoYes

Comment(s):

Orders by discipline (optional) To complete CMS485 (POC)

Medication management: Administration: Oral Injection IV-Infused Inhaled

Foley care: Yes No

Pain Management / Home prescribed exercises:NoYesElimination, Incontinence management: ___________________

NEEDS FURTHER TEACHINGExplain:

N/A N/AN/AN/AN/A

N/AN/AN/AN/AN/AN/AN/A

Yes NoPhysician follow up visits/appointments maintained: N/A

Expected Outcome:Patient unable to perform own Wound Care due toPatient unable to Insuline/Injection self administration due to

No S/O or C/G able/willing for wound care/Insulin-Injection administration at this time:

Telfa

Colostomy Supplies

Thermometer

Texas Cath

Red Box (Biohazard)

Betadine Solution

Abd Pads

Duoderm

Sharp Container

Ace band size

Leg Straps Cath

ALCOHOL PREP PADS

DUODERM CFGHY-TAPE 2''INSERTION TRAY 5CC

INSULIN SYRINGE ____ CCSYRINGES

Glucometer

MICROPORE TAPE 2"

SOFTWICK 4X4

VASELINE GAUZE 3X9

KLING 4

Medication Management, Check all that applies/identified: Potential adverse effects/drug reactionsSG

SG

Pshycological care / behaviour problems preventionN/A

Page 5 of 8 www.pnsystem.com 305.777.5580 ADULT SOC ASSESSMENT

Med. Record #PATIENT/CLIENT NAME - Last, First, Middle Initial

SN - ORDERS - FREQUENCY/DURATION:

Gene ra lSKILLED OBSERVATION/EVALUATION ASSESS VITAL SINGS & S/S COMPLICATIONS:

INSTRUCT/EVALUATE UNDERSTANDING OF DISEASE PROCESS DETECTING COMPLICATIONSDIET/NUTRITIONAL STATUS SAFETY PRECAUTION/EMERGENCY MEASURES, MED-REGIMEN

PT - ORDERS - FREQUENCY/DURATION:OT - ORDERS - FREQUENCY/DURATION:ST - ORDERS - FREQUENCY/DURATION:OTHER - ORDERS - FREQUENCY/DURATION:

21

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ACTIVITY PRIOR Level of Function I A D COMMENTS (who assists, assistive device used, etc.)Eating/Kitchen accessTransfer abilitiesDressing/GroomingBathing/ Personal CareToileting/Hygiene abilitiesAmbulation/ROMCommunication (verbal, non-verbal)Preparing/Serving light mealsPreparing full mealsLight housekeepingPersonal laundryHandling moneyUsing telephoneReading,

Managing MedicationsOther (Specify)

ACTIVITIES OF DAILY LIVING (Legend: I-Independent; A-Assist; D-Dependent)

G O A L S

DISCHARGE PLANS

Yes NoDiscussed with patient/client?

NoYesDRUG REGIMEN REVIEW COMPLETED/RECONCILIATED?PATIENT/CLIENT/CAREGIVER RESPONSE

ISUMMARY CHECKLIST SIGNATURES/DATESx / /

PatientlClientlCaregiver (optional if weekly is used) Date

/ /Professional signature/title Date

Yes NoIf needed, Branden, Flac, Timed Get Up scale/test were completed?

PATIENT/CLIENT NAME - Last, First, Middle Initial Med. Record #

2.3.4.

WritingHair care, Skin Care

www.pnsystem.com 305.777.5580 ADULT SOC ASSESSMENTPage 6 of 8

RefusedIndications for Home Health Aide may be needed:

NoYesMD Order obtained:

OTSN MSWOther Services ordered: STPT Comment:

If the patient experiment:-ADL/IADL Deficit - Elimination Deficit - Impaired Mobility:

Patient/Family:

N/A (Home Health Aide Services not needed)

SKILLED INTERVENTION/SERVICE

Instructions/Information Provided (Check all that apply):

Patient Rights and responsibilitiesState hotline/ABUSE numberAdvance directives information

Do not resuscitate (DNR) (if applicable)Service Agreement/ContractOASIS/HIPAA Privacy Notice, Confidentiality

Emergency Plan, classification, instructionsAgency phone numbers, addressClient Information Handbook

Standard precautions /handwashing/ Infection Control

Home safety guidelines

Admission criteria, Information for Home visit, Services, FrequencyDiabetes Control, other disease management information

Other

Medication sheet, instructions

Alzheimer's, Fall prevention, Sensory impairments info

Care Plans

Pain Management info Grievance Procedures

Local Resources Guide Mission, ownership information

Skilled Observation / AssessmentINJECTION ROUTE:_______ SITE: _____ MED. GIVEN: ______________________ DOSE: __________ REACTION: _____________________________

Foley Change/Care Patient Education/teaching Wound Care / Dressing Change Prep. / Admin. Insulin

Standard/Universal Precautions Followed Aseptic Tech. Used. Quality Control of Glucometer Performed Sharps Discarded Inside Sharps Container

Procedure/Tx welltolerated by Pt.

Diabetic Observation / Care

Correct handwashing technique followed SG Management/Evaluation Patient's Care Plan No caregiver/family available/willing to help patient with care, procedures.

21 AIDE - ORDERS - FREQUENCY/DURATION:TUB/SHOWER BATH PERSONAL CAREHAIR COMBORAL HYGIENETPR

ASSIST TO DRESS

WASH CLOTHESLIGHT HOUSEKEEPING

ASSIST WITH PERSONAL CARE AND ADL'SPERI CARE

REPORT SIGNIFICANT FINDING TO AGENCY/CASE MANAGEROTHER:

RETURN TO INDEPENDENT AMBULATION. BE SAFE IN SELF CARE.PATIENT WILL BE ABLE TO FUNCTION WITH ASSISTANCE OF CAREGIVERWITHIN HIS/HER CURRENT LIMITATIONS AT HOME.

GOOD/FAIR RETURN TO PREVIOUS LEVEL OF ADLS INDEPENDENTLY.

22

PATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HIS/HER CURRENT LIMITATIONS AT HOME.OTHER:

WILL DISCHARGE THE PATIENT WITHIN ____ WEEKS, WHEN PATIENT AND/ORCAREGIVER IS/ARE ABLE TO DEMONSTRATE PROPER CARE MANAGEMENT, NO S/S COMPLICATIONS.PATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HIS/HER CURRENT LIMITATION AT HOME.OTHER:

REHAB POTENTIAL LEVEL:

Yes NoPATIENT ADMISSION PACKAGE COMPLETED, AGREEMENT EXPLAINED TO PATIENT?

AIDE CARE PLAN COMPLETED, REVIEWED, EXPLAINED TO AIDE N/AFrequency of Supervision: ___________ Authorization obtained from Patient/CG N/A

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Orders by discipline (optional) To complete CMS485 (POC)

SN - ORDERS - FREQUENCY/DURATION:

Patient Name: Med. Record #

21

OTHER:

General

Psychiatric

F o l e y Care

REPORT ANY ELEVATIONS IN TEMPERATURE TO THE M.D.

Wound CareDecubitus

IMPROVE THE PT'S ABILITY TO PREVENT OR COPE WITH BREATHING DIFFICULTIES.

Asthma / Respiratory

INST. FOR S/S: EASY FATIGABILITY, DYSPNEA, PALPITATIONS, ANGINA TACHYCARDIA,PALLOR, DIZZINESS, JAUNDICE AND FEVER. INST. FOR G. I . DISTURBANCES. ASSESS FOR CENTRALNERVOUS SYSTEM SYMPTOMATOLOGY OBTAIN APPROPRIATE LAB TESTS AND REPORT FINDINGS TO M.D. ADMINISTER PRESCRIBED INJECTABLE _________________ USING ______ TECHNIQUE

Anemia

Included as reference only, your Professional Staff must review/update/personalized/approve the orders.

INSTRUCT IN PREPARATION & ADMINISTRATION OF INSULIN INSTRUCT ONSET, PEAK &DURATION OF ACTION OF INSULIN INSTRUCT PROPER DISPOSAL OF SYRINGES/NEEDLES NURSE TO MONITOR BLOOD SUGAR WITH GLUCOMETER OR ___________ON __________FREQUENCY, &NOTIFY M.D. OF ALTERED RESULTS TEACH GLUCOMETER OR __________ PROCEDURE & INTERPRETING RESULTS

InsulinGlucometer

INST. DISEASE PROCESS & COMMON COMPLICATIONS INST. PRESCRIBED DIET & SHOPPING ADVICE. INST. S/SHYPO/HYPERGLYCEMIA & EMERGENCY PROCEDURES INST. GOOD SKIN CARE & GOOD FOOT CARE, DAILY CARE OFTEETH. INST. DIABETIC CHART. INST. S&A TESTING & READING RESULTS INSTRUCT TO CARRY I.D. THAT INCLUDESINFORMATION REGARDING DIABETIC STATUS, NAMES & DOSAGE OF MEDS & ACTION TO TAKE IF INSULIN REACTION OCCURS INST. IMPORTANCE OF GOOD PERSONAL HEALTH HABITS, INCLUDING EXERCISE, ADEQUATEREST, SLEEP, REGULAR MED CHECK-UPS (INCLUDING PODIATRIC, OPTHAMOLOGIST & DENTIST).

DiabetesMellitus

INST. PACED ACTIVITY PROGRAM.

OBSERVE FOR S/S OF DECOMPENSATION SUCH AS INCREASING TACHYCARDIA, W/SUDDEN ONSET, SOB ON MIN.EXERTION, ORTHOPNEA, EXTREME ANXIETY, PROGRESSIVE CYANOSIS, GENERALIZED PALLOR AND DIAPHORESIS.CHF

INSTRUCT PROPER ADMINISTRATION OF OXYGEN THERAPY. INSTRUCT OXYGEN PRECAUTIONS.INSTRUCT MAINTENANCE OXYGEN EQUIPMENT.Oxygen

ASSESS FOR CHEST PAIN: TYPE, LOCATION, INTENSITY, DURATION & FREQUENCY I/S PAINMANAGEMENT NOTIFY M.D. IF PAIN PERSISTS. I/S GRADUAL PROGRESS ACTIVITY INCREASEINST. DISCONTINUE ACTIVITY IF CHEST PAIN, DYSPNEA, FATIGUE OR PALPITATIONS OCCUR.

Angina

PSYCHOLOGICAL ASSESSMENT ASSESS NEUROLOGICAL STATUS IMPLEMENT AND MONITOR BOWEL REGIMEN &TEACH PROGRAM TO FAMILY SN TO MONITOR TRANQUILIZER EFFECTS GIVEN FOR SEVERE AGITATION/ANXIETY.EVALUATE FOR WEIGHT LOSS, WEIGH PATIENT Q VISIT, AND RECORDS WEIGHTS MONITOR LEVEL OFCONSCIOUSNESS ASSESS COORDINATION AND BALANCE. PROVIDE EMOTIONAL SUPPORT TO PATIENT ANDFAMILY OBSERVATION AND EVALUATION OF BLADDER ELIMINATION HABITS, MANAGEMENT IF INCONTINENCE.ASSIST FAMILY IN SETTING UP ROUTINE PATIENT-CENTERED AND STRESS THE IMPORTANCE OF ADHERING.

Alzheimer's

AIDE - ORDERS - FREQUENCY/DURATION:TUB/SHOWER BATH PERSONAL CARE HAIR COMB SHAMPOO PRN MOUTH/DENTURE CARE SKIN CHECK ORAL HYGIENE TPRASSIST TO DRESS ASSIST WITH AMBULATION PREPARE SERVE MEALS GROCERY SHOP WASH CLOTHES LIGHT HOUSEKEEPING ASSIST WITH PERSONAL CARE AND ADL'SERRANDS NOTIFY LAST BM IF NONE FOR 3 DAYS FEET/NAILS CARE PERI CARE REPORT SIGNIFICANT FINDING TO SN STRAIGHTEN ROOM & CHANGE LINEN

PT - ORDERS - FREQUENCY/DURATION:EVALUATE BALANCE AND COORDINATION EVALUATE ENDURANCE, MOBILITY NEUROMUSCULAR RE-EDUCATION,PERFORM PRESCRIBED THERAPEUTIC EXERCISES NOTIFY SIGNIFICANT FINDING TO MD/AGENCY BED MOBILITY TRAININGGAIT TRAINING WITH ASSISTIVE DEVICE TEACH HOME MAINTENANCE PROGRAM AND STRENGTHENING EXERCISEEXERCISE BOTH PASSIVE AND ACTIVE EXERCISE REGIMEN TRANSFER TRAINING INSTRUCT IN SAFETY MEASURES, FALL PRECAUTIONS

OT - ORDERS - FREQUENCY/DURATION:EVALUATE PATIENT AND HOME FOR SAFETY ADL TRAINING PROGRAM MUSCLE RE-EDUCATION, BODY IMAGE TRAININGINCREASE RIGHT AND LEFT UPPER EXTREMITIES STRENGTH THERAPEUTIC EXERCISE TO (R) AND (L) HANDINCREASE STRENGTH AND COORDINATION PROPRIOCEPTION AND SENSATION.

ST FOR EVALUATION TO PROVIDE ORAL MOTOR EXERCISES INVOLVING LINGUAL AND LABIAL EXERCISES SPEECH ARTICULATION DISORDER TREATMENTIMPROVE SPEECH FACIAL SYMMETRY AND MUSCULATION IMPROVE DYSPHAGIA VOICE DISORDER TREATMENT AURAL REHABILITATION NON-ORAL COMMUNICATION LANGUAGE DISORDER TREATMENT

ST - ORDERS - FREQUENCY/DURATION:

MSW - ORDERS - FREQUENCY/DURATION:MSW FOR ASSESSMENT OF SOCIAL AND EMOTIONAL FACTORS COMMUNITY RESOURCE PLANNINGCOUNSELING REGARDING MANAGEMENT/ADJUSTMENT TO ILLNESS LONG RANGE PLANNING AND DECISION MAKING

PROVIDE SUPPORTIVE AND RELAXATION THERAPY PROVIDE FAMILY THERAPY. ASSESS INTERPERSONALBEHAVIOR ASSIST PATIENT TO DEFINE PROBLEMS & SOCIAL RELATIONSHIPS. GIVE POSITIVE REINFORCEMENT.ASSIST PATIENT TO VERBALIZE FEELINGS.

Anxie ty

INST. DISEASE PROCESS AND COMMON COMPLICATIONS INST. LOW SODIUM DIET - STRESSING IMPORTANCE OFADHERENCE MONITOR PATIENT'S BLOOD PRESSURE CLOSELY AND NOTIFY M.D OF ANY SIGNIFICANT CHANGES.INSTRUCT PT. TO AVOID OVER-THE-COUNTER COLD AND SINUS MEDS AS THEY CONTAIN VASOCONSTRICTORINST. OF HYPERTENSIVE CRISIS MONITOR FOR S/S OF ORTHOSTATIC HYPOTENSION.

Hypertension

ASSESS PSYCHOLOGICAL STATUS PROVIDE SUPPORTIVE THERAPY, PROVIDE REMOTIVATION ASSESSINTERPERSONAL BEHAVIOR. ASSIST PATIENT TO DEFINE PROBLEMS & SOCIAL RELATIONSHIPS. GIVE POSITIVEREINFORCEMENT ENCOURAGE PATIENT TO PERFORM PERSONAL HYGIENE & GROOMING ACTIVITIESASSIST PATIENT TO EXPRESS REALISTIC IDEAS & PLANS. ASSIST PATIENT TO VERBALIZE FEELINGS.

Depression

INSTRUCT PATIENT IN CONSEQUENT PHYSICAL L IMITATIONS, PLANNING AN ADEQUATE LEVEL OF DAILYACTIVITIES TEACH PT R/E ARTHRITIS S/S OF EXACERBATION. TEACH THE IMPORTANCE OF GOOD POSTURE,PREVENT TRAUMA TO JOINTS INST. PT IN THE USE OF ASSISTIVE DEVICE AS PRESCRIBED.

Osteoarthritis

SKILLED OBSERVATION/EVALUATION ASSESS VITAL SINGS & S/S COMPLICATIONS:INSTRUCT/EVALUATE UNDERSTANDING OF DISEASE PROCESS DETECTING COMPLICATIONSDIET/NUTRITIONAL STATUS SAFETY PRECAUTION/EMERGENCY MEASURES, MED-REGIMEN

PSYCH ASSESSMENT: ASSESS FOR S/S OF EPSDETECT AND ALLEVIATE SOMATIZED COMPLAINTSLIMIT SETTING MOTIVATION TECHNIQUES, IMAGERY TECHNIQUES

RELAXATION TECHNIQUESGOAL ORIENTED TASKS

FOLEY INSERTION _______FR. FOLEY WITH___________cc BALLONCHANGE Q MONTH & PRN x3 FOR CLOGGED, LEAKING, OR ACCIDENTAL REMOVALINST. DRESSING CHANGES ________________________. MONITOR FOR S/S COMPLICATIONS & NOTIFY M.D.

INST. S/S INFECTION

MONITOR STATUS OF WOUND OR DECUBITUS (place) ______________INST. INFECTION CONTROL MEASURES

INST. GOOD NUTRITION TO FACILITATE HEALINGMEASURE AND RECORD WOUND or DECUBITUS SIZE AT SOC AND AT LEAST WEEKLY THEREAFTEROPEN WOUND CARE/DRESSING: CLEANSE WOUND WITH ___________, TO RINSE WITH __________ AND APPLY______________ AND PRN

OBSERVE AND RECORD TYPE AND AMOUNT OF DRAINAGE, COLOR, INFECTION: SWELLING, REDNESS, PAINDE CUB ITUS CAR E/DR ESS ING: CLEAN SE W OUN D WITH ___________, TO R IN SE WITH __________ AN D APP LY ______________ AN D PR N

TEACH THE PATIENT HOW TO USE A METERED-DOSE INHALER MAINTAIN EFFECTIVE AIRWAY CLEARANCE

EMPHASIZE THE IMPORTANCE OF ADEQUATE DAILY FLUID INTAKE

PROMOTE AN EFFICIENT BREATHING PATTER

INST. INFECTION CONTROL & PULMONARY HYGIENE INST. COMPLICATIONS IN CARDIOPULMONARY STATUSINST. PREVENTION OF COMPLICATIONS: IE: AVOID OVER-EXERTION, CHILLING, CROWDS, ETC.

INST . D ISEASE PROCESS & MAINTENANCE

INSTRUCT COUGHING, DEEP BREATHING EXERCISES. INST. PATIENT TO MAINTAIN ADEQUATE REST PATTERN.

MANAGEMENT AND EVALUATION OF A PATIENT CARE PLAN TEACHING AND TRAINING : DISEASE PROCESS SKIN CARE, WOUND CARE/DRESSING CHANGE, DECUBITUS CARE MEDICATION REGIMEN

DIET/NUTRITION/HYDRATION COMPLICATIONS OF ENT. FEEDING AS INDICATED PAIN CONTROL MEASURES, SYMPTOM CONTROL MEASURES SINGS/SYMPTOMS OF INFECTION, SAFETY/PREVENTION OF INJURY EMERGENCY PLANS OXYGEN ADMINISTRATION

General

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G O A L S / R E H A B I L I T A T I O N P O T E N T I A L ( O p t i o n a l ) C M S 4 8 5 ( P O C )Included as reference only, your Professional Staff must review/update/personalize/approve the goals.

DISCHARGE PLANNING DISCUSSED WITH PATIENT: Yes No REHAB POTENTIAL: ExcellentPoor Fair Good

COMMENTS

QA Date Reviewed: //

22

SN - GOALSMR/MS _________________ WILL EXHIBIT VITAL SIGNS WITHIN ACCEPTABLE RANGE AND STABILIZED DISEASE PROCESS.VERBALIZES KNOWLEDGE OF DISEASE MANAGEMENT, MEDICATIONS, SIDE EFFECTS, PRECAUTIONS, DIET, FLUIDS, TREATMENT PROGRAM, S/S NECESSITATING MEDICAL ATTENTION, EMERGENCY CARE.

STABILIZATION OF PSYCHOLOGICAL STATUS WITHIN DISEASE LIMITS. TO REDUCE THE PATIENT'S ANXIETY LEVEL.DEPRESION/ANXIETY CONTROLED TROUGH MED. REGIMEN/ INTERVENTIONS.

ANEMIA CONTROLLED THROUGH MED. REGIMEN. IMPROVED HEMATOLOGIC STATUS.

General

Psychiatric

A n e m i aHEALED WOUND WITHOUT INFECTION OR COMPLICATIONS. DEMONSTRATE PROPER WOUND CARE.

Wound Care

PT/S.O. SHOULD UNDERSTAND THE NATURE, SYMPTOMS, STAGE, AND PROGRESSION OF ALZHEIMER'S DISEASE.KNOW HOW TO RECOGNIZE PT'S OWN STRESS AND WAYS TO PREVENT OR REDUCE IT. PROMOTE SOCIAL INTERACTION AS TOLERATED BY THE PATIENT.

Decubitus

DEMONSTRATE STRATEGIES TO BE USED DURING A COUGHING EPISODE. HELP THE PATIENT IDENTIFY FACTORSTHAT MAY CAUSE ASTHMA ATTACKS OR CONTRIBUTE TO THEM.Asthma

SAFELY ADMINISTERS INJECTION. COMPREHEND RATIONALE FOR AND IS ABLE TO ROTATE INJECTION SITES.COMPREHEND SAFETY FACTORS IN SYRINGE/NEEDLE DISPOSAL.PATIENT/CG ABLE TO MONITOR BLOOD SUGAR CORRECTLY WITHOUT ASSISTANCE.ABLE TO NOTIFY M.D. OF ALTERED/OUT OF RANGE RESULTS.

InsulinGlucometer

DISCHARGE PT WHEN BLOOD SUGARS ARE WITHIN THE NORMAL FOR PATIENT RANGE.KNOW THE ACCEPTABLE RANGE FOR BLOOD SUGAR LEVEL. COMPLY WITH DIET RESTRICTIONS.. Diabetes

MellitusRETURN TO SELF-MANAGEMENT OF HEALED FRACTURED.

FractureKNOW ABOUT SIGNS, SYMPTOMS, AND PRECIPITATING CAUSES OF CHF. KNOW HOW TO TAKE THE PULSE AND KNOWTO CONSULT THE DOCTOR BEFORE CONTINUING MEDICATION IF THE PULSE RHYTHM CHANGES. KNOW TOA V O I D S M O K I N G A N D S M O K Y E N V I R O N M E N T S A N D P E R S O N S W I T H I N F E C T I O N S , E S P E C I A L L Y R E S P I R A T O R Y I N F E C T I O N S .

CHF

UNDERSTAND THAT HYPERTENSION IS A CHRONIC DISEASE REQUIRING LIFE LONG TREATMENT. EXHIBIT BLOODPRESSURE READINGS CONSISTENTLY WITHIN NORMAL OR SPECIFIED RANGE. DEMONSTRATE ADHERENCE TO ALOW-SALT, LOW-FAT DIET.

Hypertension

HELP THE PATIENT ACHIEVE PAIN RELIEVE AND REDUCE ANGINA EPISODES. UNDERSTAND THE CAUSE OFANGINA PECTORIS AND POSSIBLE PRECIPITATING FACTORS FOR AN ATTACK. IDENTIFY PERSONAL STRESSORSTHAT MAY CONTRIBUTE TO THE PROBLEM AND BEGIN ELIMINATING OR MINIMIZING THEM. KNOW WAYS TOREDUCE THE FREQUENCY OF ANGINA EPISODES.

Angina

HEALED DECUBITUS WITHOUT INFECTION OR COMPLICATIONS. DEMONSTRATE PROPER DECUBITUS CARE.

Alzheimer's

UNDERSTAND S/S OF BRONCHITIS OR OTHER RESPIRATORY INFECTION, AND DISEASE EXACERBATION.UNDERSTAND THE DANGERS OF SMOKING, AIR AND CHEMICAL POLLUTANTS, AND RESPIRATORY INFECTION.UNDERSTAND AND PRACTICE COUGHING AND DEEP-BREATHING EXERCISES.

Respiratory

DAILY COMPLIANCE W/CATHETER CARE. DECREASE RISK OF URINARY INFECTION.Catheter

INCREASED PAIN RELIEF. INCREASED STRENGTH AND ENDURANCE. COMPREHEND AND DEMONSTRATE HOME EXERCISE.Osteoarthritis

AIDE - GOALS

GAIT PATTERN, ENDURANCE, STRENGTH AND BALANCE WILL IMPROVE AND PATIENT WILL DEMONSTRATECORRECT BODY MECHANICS W/IN 4-6 WKS. PT/CG WILL COMPREHEND AND DEMONSTRATE HOME EXERCISEPROGRAM WITHIN 4-6 WKS.

FAIR-TO BE ABLE TO CARRY OUT MINIMAL ADLS WITH AVAILABLE HOME SUPPORT.WILL NOT BE ABLE TO CARRY OUT ADLS WITHOUT MAXIMUM SUPPORT.

RETURN TO INDEPENDENT AMBULATION. BE SAFE IN SELF CARE.PATIENT WILL BE ABLE TO FUNCTION WITH ASSISTANCE OF CAREGIVERWITHIN HE/SHE CURRENT LIMITATIONS AT HOME.

PATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HIS/HER CURRENT LIMITATIONS AT HOME.

PT - GOALS

GOOD RETURN TO PREVIOUS LEVEL OF ADLS INDEPENDENTLY.

GAIT PATTERN, ENDURANCE, STRENGTH AND BALANCE WILL IMPROVE AND PT WILL DEMONSTRATECORRECT BODY MECHANICS WITHIN _____ WEEKS.

PATIENT WILL EXPERIENCE A DECREASE IN PAIN

PT/CG WILL COMPREHEND AND DEMONSTRATE HOME EXERCISEPROGRAM WITHIN _____ WEEKS.

OT: PATIENT WILL EXHIBIT IMPROVEMENT IN COPING IN ADL'S/IADL'S/ MUSCLE USE/MOTORCOORDINATION/NEURO RESPONSE/USE OF ORTHOTIC/ SPLINTING AND/OR EQUIPMENT.

OT - GOALS

PATIENT WILL DEMONSTRATE FUNCTIONAL COMMUNICATIONS, EXHIBIT MAXIMUM VERBAL AND SENTENCEFORMULATION AND COMPREHENSION WITHIN DISEASE LIMITS WITHIN _____ WEEKS.

ST - GOALS

PATIENT WILL DEMONSTRATE APPROPRIATE USE OF FUNCTIONAL VERBAL/NON-VERBALCOMMUNICATIONS SYSTEMS WITHIN _____ WEEKS.

PATIENT WILL DEMONSTRATE IMPROVED READING/WRITING, USE OF GESTURES/NUMBERS WITHIN _____ WEEKS.

PATIENT WILL DEMONSTRATE IMPROVED SWALLOWING/CHEWING/ORAL/MOTOR CONTROL WITHIN _____ WEEKS.

PATIENT WILL HAVE ADEQUATE SUPPORT TO REMAIN IN HOME WITH ASSISTANCE OF COMMUNITYRESOURCES FOR FINANCIAL, TRANSPORTATION AND PERSONAL CARE ASSISTANCE WITHIN _____ WEEKS.

MSW - GOALSPSYCHOSOCIAL EVALUATION WILL BE PERFORMED. PT/CG WILL BE COUNSELED REGARDING MANAGEMENT& ADJUSTMENT TO ILLNESS /LONG TERM PLANNING AND DECISION MAKING. APPROPRIATE COMMUNITYRESOURCE REFERRALS WILL BE MADE.

WILL DISCHARGE THE PATIENT WITHIN 60 DAYS WHEN PATIENT AND/ORCAREGIVER IS/ARE ABLE TO DEMONSTRATE KNOWLEDGE OF DISEASE MANAGEMENT, S/S COMPLICATIONS.PATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HIS/HER CURRENT LIMITATION AT HOME.

ABLE TO REMAIN IN HOME/RESIDENCE/ALF WITH ASSISTANCE OF PRIMARY CAEGIVER/SUPPORT AT HOMEABLE TO UNDERSTAND MEDICATION REGIMEN, AND CARE RELATED TO HIS/HER DISEASE.WILL BE DISCHARGE WHEN MAXIMUM FUNCTIONAL POTENTIAL REACHED.

Patient Name: Med. Record #:

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TIME IN: TIME OUT: Agency Name: Physician name: Phone: Address 1: Address 2: undefined_6: Phone Number: Reason: Other Physician if any: Address 1_2: Address 2_2: Patient Name: Phone Number_2: Address: NA: 6: Patient Phone: undefined_8: Social Security Number: Phone_2: Fax: Name: EmergencyDisaster Plan Classification Code: Phone_3: EMERGENCY CONTACT: Address_2: Phone_4: Relationship: OTHER: Reason_2: Evacuat: Yes specify: CHIEF COMPLAINT 1: CHIEF COMPLAINT 2: Other specify: PRESENT ILLNESSNURSING DIAGNOSIS 1: PRESENT ILLNESSNURSING DIAGNOSIS 2: PRESENT ILLNESSNURSING DIAGNOSIS 3: Sittinglying R: Temperature: Standing R: L: L_2: Apical: Fractures: Cancer site: Respirations: Radial: Carotid: Surgeries: Other: 12 1: 12 2: undefined_11: undefined_12: 1: 2: undefined_13: undefined_14: undefined_15: undefined_16: 1_2: undefined_17: undefined_18: undefined_19: undefined_20: 1_3: 2_3: Date_5: undefined_21: undefined_22: Date_6: undefined_24: Frequencyduration: Infections: Other specify_3: Cataract surgery Site 1: Cataract surgery Site 2: Date_7: undefined_25: undefined_26: Other specify incl hx: specify: Irreg specify: Pulse deficit specify: Other specify incl hx 1: Other specify incl hx 2: Dependent: Nonpitting site: Thrombus Site: Rx: MassesNodes Site: Size: Cramps LEUENight site: Alopecia 1: Alopecia 2: Cyanosis site: Other specify incl hx_2: Pacemaker Date: undefined_27: undefined_28: Type: Other specify incl hx_3: 1_4: 2_4: Nose surgery 1: Nose surgery 2: Other specify incl hx 1_2: Other specify incl hx 2_2: undefined_29: Dentures Upper Lower Partial: undefined_30: Productive ThickThinDifficult Color: Smoker: packsday X: Any mouth surgeryprocedure: Exertion amb feet: Other specify incl hx_4: during ADLs: Orthopnea of pillows: Fremitus Location: Hemoptysis Frequency: Amt: Diabetes Type IType II Onset: undefined_31: undefined_32: DietOral control X: L_3: Meddosefreq: Insulindosefreq: 02 Sat: 02 use: Blood Sugar Range: SelfcareSelfobservational tasks specify: Other specify incl hx 1_3: Other specify incl hx 2_3: undefined_33: Other specify incl hx 1_4: Other specify incl hx 2_4: 6Endurance: 9Legally blind: OffB Other specify: OffGeneral: OffArthralgia: OffEdema in: Chest pain on exert: OffOther specify_4: undefined_34: Nocturia x: Bloodtinged: Other_2: Clarity: No: Urinary Catheter Type: Last changed on: Foley inserted date: with: Inflated balloon with: Irrigation solution Type specify: mL Frequency: Urostomy describe skin around stoma: Other_3: Frequency: Amount_2: 7Independent in home: Lives wothers: Other 1: Other 2: Primary caregiver name: RelationshipHealth status: Other specify_5: YES: SecondaryOther caregivers describe 1: SecondaryOther caregivers describe 2: Eats fewer than 2 meals per day: 3_2: Eats few fruits vegetables or milk products: 2_5: 2_6: 2_7: Does not always have enough money to buy the food needed: 4: 1_5: 1_6: 2TOTAL: Hemophilia other: Malignancies specify: Prior Rx: Complications: Other specify immunolog: cal problem: Last BM: undefined_41: undefined_42: Usual frequency: Oriented X: MucusPainFoul odorFrothy Amount: LaxEnema use Type: Freq: Rx specify: Headache Loc: Freq_2: Flatulence Freq: Incontinence of stool Freq: Weakness UELE Location: Abdominal distention CrampingPain Freq: Ascites Girth: Hand grips EqualUnequal specify: FirmTender X: Bowel sounds ActiveHyperactive X: StrongWeak specify: Absent X: undefined_43: undefined_44: Psychotropic drug use specify: Colostomy SigmoidTransverse Date: DoseFreq: Other specify incl hx 1_5: Other specify incl hx 2_5: Depressed RecentLong term Fix: Creole: OffRuss: Offan: Needs interpreter: fy: Phone No: Spiritual resource: 1 Oriented: Off3 Forgetful: Off7 Agitated: Off4 Depressed: Off6 Lethargic: OffPlan: 8 Other: OffForgetful at times: OffNO PROBLEM: Irritable: OffAnxious: OffAlert: OffOther_4: Cardiac Precautions: Phone_5: Sutures Staples Turgor Good Poor Edema Lymph Hema Other specify incl pertinent hx NO PROBLEM Denote location of specific skin conditionswounds by numbering appropriately on illustrations below Itch Rash Dry Scaling Incision Wounds Lesions Decubitus Fistulas Abrasions Lacerations Bruises Ecchymosis Pallor Jaundice Redness: Location: Origin: Onset: undefined_45: Present Pain Management Regimen 1: Present Pain Management Regimen 2: Other specify incl pertinent hx 1: Other specify incl pertinent hx 2: Effectiveness 1: Effectiveness 2: Other specify 1: Other specify 2: FreqDuration 1: FreqDuration 2: ngRelieving Factors: i: Pain Management History 1: Pain Management History 2: Yes: Fall risk assessment conducted every: Comment: DrainageAmt: Tunneling: Other_5: Fracture location: Swollen painful joints specify: Contractures Joint: Location_2: Decreased ROM: Paresthesia: Amputation BKAKUE RL specify: Other specify incl pertinent hx: IV: Pump typespecify: Bolus: Prosthesis: Comment_2: ORDERS FREQUENCYDURATION: Comment_3: undefined_46: PRIOR Level of FunctionEatingKitchen access: IEatingKitchen access: AEatingKitchen access: DEatingKitchen access: COMMENTS who assists assistive device used etcEatingKitchen access: PRIOR Level of FunctionTransfer abilities: ITransfer abilities: ATransfer abilities: DTransfer abilities: COMMENTS who assists assistive device used etcTransfer abilities: PRIOR Level of FunctionDressingGrooming: IDressingGrooming: ADressingGrooming: DDressingGrooming: COMMENTS who assists assistive device used etcDressingGrooming: PRIOR Level of FunctionBathing Personal Care: IBathing Personal Care: ABathing Personal Care: DBathing Personal Care: COMMENTS who assists assistive device used etcBathing Personal Care: PRIOR Level of FunctionToiletingHygiene abilities: IToiletingHygiene abilities: AToiletingHygiene abilities: DToiletingHygiene abilities: COMMENTS who assists assistive device used etcToiletingHygiene abilities: PRIOR Level of FunctionAmbulationROM: IAmbulationROM: AAmbulationROM: DAmbulationROM: COMMENTS who assists assistive device used etcAmbulationROM: PRIOR Level of FunctionCommunicat on verba nonverbal: ICommunicat on verba nonverbal: ACommunicat on verba nonverbal: DCommunicat on verba nonverbal: COMMENTS who assists assistive device used etcCommunicat on verba nonverbal: PRIOR Level of FunctionPreparingServing light meals: IPreparingServing light meals: APreparingServing light meals: DPreparingServing light meals: COMMENTS who assists assistive device used etcPreparingServing light meals: PRIOR Level of FunctionPreparing full meals: IPreparing full meals: APreparing full meals: DPreparing full meals: COMMENTS who assists assistive device used etcPreparing full meals: PRIOR Level of FunctionLight housekeeping: ILight housekeeping: ALight housekeeping: DLight housekeeping: COMMENTS who assists assistive device used etcLight housekeeping: PRIOR Level of FunctionPersonal laundry: IPersonal laundry: APersonal laundry: DPersonal laundry: COMMENTS who assists assistive device used etcPersonal laundry: PRIOR Level of FunctionHandling money: IHandling money: AHandling money: DHandling money: COMMENTS who assists assistive device used etcHandling money: PRIOR Level of FunctionUsing telephone: IUsing telephone: AUsing telephone: DUsing telephone: COMMENTS who assists assistive device used etcUsing telephone: PRIOR Level of FunctionReading Writing: IReading Writing: AReading Writing: DReading Writing: COMMENTS who assists assistive device used etcReading Writing: PRIOR Level of FunctionHair care Skin Care: IHair care Skin Care: AHair care Skin Care: DHair care Skin Care: COMMENTS who assists assistive device used etcHair care Skin Care: PRIOR Level of FunctionManaging Medications: IManaging Medications: AManaging Medications: DManaging Medications: COMMENTS who assists assistive device used etcManaging Medications: PRIOR Level of FunctionOther Specify: IOther Specify: AOther Specify: DOther Specify: COMMENTS who assists assistive device used etcOther Specify: OTHER 1: OTHER 2: REHAB POTENTIAL LEVEL: Other_6: INJECTION ROUTE: MED GIVEN: DOSE: REACTION: Correct handwashing technique followed SG: PATIENTCLIENTCAREGIVER RESPONSE 1: PATIENTCLIENTCAREGIVER RESPONSE 2: x: undefined_47: undefined_48: undefined_49: undefined_50: SOCM: SOCD: SOCY: FDM: FDD: FDY: TOM: TOD: TOY: PT ID PERFORMED VIA NAME DOB FACE RECOGNITION AND ADDRESS BEFORE SERVICE PROVIDED: Offrsna: OffDM: DD: DY: rdy: rdm: rdd: birdat: bida: bd: gend: Offndc: Offreho: Offutd: Offinflu: Offpneu: Offtet: Offblopre: Offh1n1: Offoral: Offaxil: Offrect: Offtymp: Offchsto: Offapic: Offbrac: Offcarot: Offdearatt: Offapn: Offre: Offr: Offfract: Offimmun: Offcard: Offcanc: Offopw: Offsurg: Offresp: Offost: Offinsd: Offninsdep: Offinf: OffBlood Pressure: DLCM: DLCD: DLCY: prevoutc: Date_3: Date_2: Date_4: Date: undefined_9: undefined_10: Radio Button11: OffFL4: OffFL6: OffFL9: OffFL1l: OffFL1b: OffFL1d: OffFL1p: OffFL1li: OffFL2: OffFL3: OffFLb: OffFLart: OffFLhead: OffFLanx: OffFLprod: OffFLg: OffFL8: OffFLdiz: OffFLins: OffFLheart: OffFLp: OffFLu: OffFLv: OffFLed: OffFLc: OffFL1lr: OffFL1lc: OffFL1f: OffFL1n: OffFL5: OffFL7: OffA-Dyspnea with: Off19108: Off19109: Off1910aw: Off1910bw: Off1910cnr: Off1910do: OffDOther specify: pslb: Offpsni: Offlbm: Offurw: OffHigher Educational Level: sceri: Offpsfat: Offpsdisc: Offpsan: Offpswit: Offpsdif: Offpsdis: Offgfrpl: Offoth: Offglass: Offcont: Offprot: Offinfec: Offcatsurg: Offother: Offglauc: Offblurvis: Offlegblind: Offjaund: Offptos: Offhoh: Offdeaf: Offtinn: Offhear: Offsns: Offssc: Offmass/nod: Offalopec: Offcong: Offlos: Offnossurg: Offepist: Offsinp: Offdysp: Offnpro: Offles: Offotsp: Offhoar: Offsoreth: Offnop: Offdent: Offgingiv: Offamsp: Offulcer: Offotspe: Offmasstum: Offtooth: Offnprobl: Offchpain: Offang: Offpost: Offlocal: Offsubst: Offrad: Offvilke: Offsharp: Offdull: Offache: Offpalp: Offirreg: Offr/i: Offorthyp: Offsync: Offvert: Offreg: Offregul: Offirre: Offbp: Offpuldef: Offedema: Offped: Offdep: Offpitt: Offnon-pitt: Offclau: Offjvd: Offfatig: Offthrom: Offsob: Offact: Offsweats: Offcram: Offcyan: Offcapref: Offpulse: Offpacem: Offot: Offnp: Offcough: Offprod: Offsmok: Offdyspn: Offrest: Offexert: Offorthop: Offcrep: Offbarrch: Offchlob: Offfrem: Offoxiuse: Offoxyprec: Offothe: Offenlth: Offfati: Offintole: Offdiab: Offdiet: Offmdf: Offidf: Offmos: Offyears: Offhyp: Offhypog: Offbsr: Offscsot: Offothersp: Offnpr: OffOxysat: Offchlo: Offby: Offcol: Offclarity: Offodor: Offptpw: Offburn: Offhesit: Offhemat: Offo/a: Offu/f: Offnoct: Offinc: Offuri: Offbow: Offdiap: Offuricat: Offwdif: Offurost: OffFirst: MI: Last: Suffix: Med Record: HBR11: OffHBR12: OffHBR13: OffMobilityAmbulatory devices used: Other specify_2: undefined_23: 16lowna: Off16concar: Off16lowcho: Off16nas: Off16npo: Off161800cal: Off162gm: Off16lowfat: Off16incflu: OffOther_19: 16exc: OffIncrease fluids: Restrict fluids: 16anore: Off16poor: Off16fair: Off16restflu: Off16good: Off16other: Off16vom: OffFrequency_2: Amount: 16nau: Off16heabur: OffFrequency_3: Other 1_2: Other 2_2: hou: Offapart: Offnewenv: Offfampres: Offlivalone: Offlivwoth: OffasswADLs: Off19101: Off19102: Off19103: Off19104: Off19105: Off19107: Off19106: Offppc: Offospec: Offsecond: Offgeninf: Offgensurg: OffProstate problem BPH TURP Date: undefined_53: undefined_54: Selftesticular exam Frequency: genhyst: OffHysterectomy Date: undefined_55: undefined_56: Date last PAP: undefined_57: undefined_58: Results: Breast selfexam frequency: gendisc: OffMastectomy R L Date: undefined_59: undefined_60: Other specify_6: gennp: OffOther specify_7: anem: Off2obleed: Offthromb: Offgen dis: Offgenles: Offgenprost: Offgensef: Offgenmeno: Offgenbre: Offgenmast: Offgenoth: Offcoag: Offhemop: Offmalig: Offnoprob: Offsmrp: Offsmpic: Offsmst: Offsmlasa: Offsmsp: Offsmcc: Offpump: Offsmep: Offsmcou: Offsmpes: Offsmwd: Offsmal: Offsmpco: Offsmgip: Offsmcp: Offsmtsc: Offsmght: Offsmsd: Offsmpfi: Offsmms: Offsmpup: Offsmsa: Offsmgup: Offsmcpat: Offsmcfsh: Offsmcht: Offoxyg: Offfirealarm: Offsmokalarm: Offsh: Offih: Offhd: Offfab: Offug: Offir: Offus: Offnta: Offpp: Offsf: Offmss: Offep: Offev: Offsb: Offadce: Offppf: Offrma: Offhsd: Offallerno: Offalleasp: Offalleggs: Offallepen: Offalleib: Offallesulf: Offallead: Offalledm: Offallepol: Offalledust: Offallelod: Offalleother: OffOther 1_3: par: Offmswea: Offmsqua: Offmspa: Offmscan: Offmswal: Offmsad: Offpoorcond: Offcrut: Offlifts: Offbedside: Offprost: Offmsother: Offhospbed: OffSOBFT: ret: bs: OffHBR7: Offslsp: Offsyn: Offsenloss: Offnumb: Offimpdec: Offmemloss: Offhead: Offapha: Offweak: Offtrem: Offstup: Offuneq: Offpsych: Offorient: Offinsom: Offatax: Offhxofreq: Offnopro: Offnopr: Offpsuic: Offsudat: Offdepres: Offlacom: Offdiarrh: Offdia3: Offasgtfb: Offconst: Offlax: Offhemorrh: Offrx: Offflatul: Offimpact: Offincontin: Offabdom: Offascit: Offabsent: Offcolost: Offnprbl: Offinabrp: Offunrexp: Offdenop: Offotspecfy: Offinaprcc: Offinapftip: Offinvisr: Offevidoa: Offpoten: Offactu: OffHBR8: OffHBR9: OffHBR10: Offverbemo: Offfinanc: Offphysic: Off1orient: Off3forget: Off5disorient: OffHBR1: OffHBR2: OffHBR3: OffHBR4: OffHBR5: OffHBR6: Off2comatose: Offnoprblm: OffEnglish: OffSpanish: OffRussian: OffSKINITCH: OffSKINRASH: OffSKINDRY: OffSKINSCL: OffSKINRED: OffTURGGP: OffSKINBRU: OffSKINECCH: OffSKINPALL: OffSKINJAU: Offincis: Offwoun: Offlesions: Offdecub: Offfist: Offabras: Offlacerat: Offsut: Offstap: Offlymph: Offhama: Offnopbl: Offfrace: OffSKINNP: Offfppippi: OffEFAD TPN: OffEFAD jej: OffEFAD Nas: Offefad gas: Offfeedtype: OffEFAD iv: OffEFAD pum: OffEFDA bol: OffEFDA con: Offfapm: Offmdobt: Offn/ahhas: OffEFDA na: Offcomm: Offmsamp: Offmshe: Offmsoth: Offtub/sho: Offperscare: Offhacomb: Offorhyg: Offrepsig: Offmsfr: Offmssw: Offmscon: Offmsat: Offmssh: Offmsdec: Offpeca: Offdnr: Offsac: Offopnc: Offmsi: Offhsg: Offafpsii: Offgriproc: Offlrg: Offmoi: Offdpwdp: Offdpother: Offsoa: Offfcc: Offpe: Offwcd: Offpai: Offdoc: Offinjr: OffSkilled Observation Assessment: sup: Offpt: Offatu: Offsd: Offcht: Offmep: Offncfa: OffCorrect handwashing technique followed SG 2: Correct handwashing technique followed SG 3: dwp/c: Offdrrc: Offaofdoth: Offrefus: Offwdtpw: ms/rfo: Offprr: Offshan: Offadi: Offepci: Offapna: Offcihb: Offpmi: Offsphic: Offacihvsf: Offdcdmi: Offcapla: Offccst: Offccmsw: Offccsn: Offccaide: OffFL1pv: OffFLfat: OffFL1: OffFLsob: Offskin: Off2_8: 2_9: piptf: OffMAN: Clear Form: ms/rfo2: Offcp: Offph: Offsn: Offst: Offmsw: Offaid: Offmfc: Offnch: Offoo: OffO: mmc: Offidt: Offsse: Offsdi: Offncwdo: Offddt: OffNoncompliance with drug orders: eo: OffExpected Outcome: pup: Offpui: OffPatient unable to perform own Wound Care due: Pat: no s/o-c/g: Offto: salin: Off2x2: Off4x4: Offabd: Offtelf: Offtap: Offwg: Offglov: Offhyd: Offks: Offnancg: Offtd: Offoint: Offcs: Offther: Offrb: Offns: OffHydrocolloids: Ointment: Angiocatheter size: ic: Offivsk: Offivp: Offivt: Offas: Offasi: Offundefined_68: per: Offet: Offcid: Offip: Offperbs: Offetss: Offcidduo: Offipbs: Offabs: Offm2x11: Offmt2: Offs4x4: Offabdp: Offund: Offec: Offub: Offop: Offow: Offsat: Offstca: Offfol: Offls: Offaa: Offotth: Offcta: Offapp: Offis: Offsyr: Offchem: Offdcfg: Offhyt: Offit: Offes: Offft: Offsrk: Offstrk: Offststi: Offta: Offvg: Offkl: Offsr: Offbath: Offcan: Offcom: Offsmo: Offprd: Offegg: Offhb: Offhl: Offefp: Offneb: Offoc: Offoxyvent: Offoxywalk: Offoxywhe: Offoxyten: Offoxygsuct: Offqc: Offwdc: Offdmc: Offiad: Offgc: Offnmd: Offtrc: Offoca: Offfc: Offor: Offinj: Offivinf: Offinh: Offpfv: Offoup: Offuhm: Offpmh: Offadl: Offe911: Offcpdv: Offpcbp: Offpuitc: Offdmeund1: dmeund2: dmeund3: dmeund4: dmeund5: dmeund6: dmeund7: dmeund8: dmeund9: dmeund10: dmeund11: dmeund12: dmeund13: dmeund14: dmeund: dmeund16: dmeund17: dmeund18: dmeund15: dmeund19: dmeund22: dmeund23: Pain Management History 3: qbda: 1-1: 2-2: 3-2b: 3-3c: 3-4d: 4-2: 4-3: 3_3: 4-4: oxyot: Offsoeav: Offieud: Offdecom: Offdstm: Offnftg: Offspem: Offpoeim: obdtc2: obdtc3: obdtc4: obdtc5: obdtc1: obdtc6: snofd2: snofd3: snofd4: snofd5: snofd6: snofd7: snofd8: mdrcd: afdo: snofd1: tpre: pcgu: pcgu1: dte1: dte2: diag6: Depth Stage2: Depth Stage3: Depth Stage4: Depth Stage5: Depth Stage: Depth Stage1: Depth Stage6: Depth Stage7: Odor Sur Tis2: Odor Sur Tis3: Odor Sur Tis4: Odor Sur Tis5: Odor Sur Tis: Odor Sur Tis1: Odor Sur Tis6: Odor Sur Tis7: Edema Stoma2: Edema Stoma3: Edema Stoma4: Edema Stoma5: Edema Stoma: Edema Stoma1: Edema Stoma6: Edema Stoma7: glu: Offtxcat: OffMR: SN ORDERS FREQUENCYDURATION: ipai: Offiop: Offko: Offds: Offiudp: OffS COMPLICATIONS: dc: Offnmbs: Offsnofdi: Offsnofsa: Offtg: OffTH GLUCOMETER OR: ON: sfcp: Offispm: OffTEACH GLUCOMETER OR: snofno: Offipd: Offida: Officid: OffNSERTION: TH: cqm: Offfi: Offidc: Offissi: Offigp: OffINST DRESSING CHANGES: ief: OffMONITOR STATUS OF WOUND OR DECUBITUS place: iicm: Offifdat: Offnss: Offign: Offmrw: Offpcd: Offdccw: Offort: Offapi: OffADMINISTER PRESCRIBED INJECTABLE: pst: Offsib: OffUSING: aps: OffTH_2: TH_3: AND APPLY: sdp: OffCLEANSE WOUND WITH: NSE WITH: AND APPLY_2: ippph: Offaperi: Offps: Offpf: Offepum: Offmeac: Offap: Offidp: Offiiph: Offiap: Offipc: Officdb: Offipap: Offpebp: Offans: Offimb: Officcs: Offimt: Offapv: Offpa: Offmlc: Offipm: Offacb: Offafs: Offeob: Offeiad: Offewl: Offipaot: Offpaa: Offrt: Offdas: Offgot: Offodit: OffOTHER_2: lsm: Offdpc: Offils: Offmpb: Offmepc: Offttdp: Offscwc: Offmr: Offdn: Offcef: Offpcm: Offsi: Offiao: Offihc: Offipcp: Offmfs: Offtae: Offeplan: Offoa: Offspi: Offiua: Offtsb: OffDE ORDERS FREQUENCYDURATION: sp: Offsc: Offad: Offpc: Offhc: Offmdc: Offoh: Offtpr: Offawa: Offnlb: Offpsm: Offgs: Offlhk: Offawpc: Offfnc: Offwc: Offpric: Offrsf: Offerrand: Offsrc: OffPT ORDERS FREQUENCYDURATION: ebc: Offppt: Offgtwa: Offebp: Offeem: Offnme: Offnsf: Offbmt: Offthm: Offtt: Offism: OffOT ORDERS FREQUENCYDURATION: ofeva: Offofinc: Offofinst: Offatp: Offmre: Offte: Offpas: OffST ORDERS FREQUENCYDURATION: sfe: Offisp: Offar: Offpom: Offsad: Offfsm: Offidy: Offvdt: Offnoc: Offldt: OffMSW ORDERS FREQUENCYDURATION: mfa: Offcrp: Offcrm: Offlrp: Offmrms: OffMRMS: saic: Offsps: Offdptw: Offacmr: Offrsm: Offhwi: Offhdic: Offkss: Offpsn: Offuhc: Offdsdc: Offhpa: Offusb: Offipi: Offdcw: Offgrp: Offftcm: Offwac: Offpaf: Offpafi: Offpwe: Offria: Offges: Offptc: OffPROGRAM WITHIN: CORRECT BODY MECHANICS WITHIN: otp: Offpwdf: Offstgwk1: COMMUNICATIONS SYSTEMS WITHIN: phas: Offstgwk3: stgwk2: pdi: Offpdis: Offpdaf: Offpep: Offmswgwk1: dpdp: Offrhpoor: Offrp: Offfname: OffRehabdc1: OffQA Date Reviewed: undefined_77: undefined_78: E-mail Form: