Patient Visit Record

: date; ?>

: day; ?>

: timeIn; ?>

: timeOut; ?>

: patientName; ?>

: dob; ?>

: diagnosis; ?>

: allergy; ?>

: md_name; ?>

: id_confirmed; ?>

: Reason; ?>

: type_of_therapy; ?>

: visit_activity; ?>

: types_of_device_access; ?>

: accessAssessment; ?>

: action; ?> > action_value; ?>

: pump_bettery_change; ?>

: pump_res_volume; ?>

: pump_rate; ?> > pumpRateValue; ?>

: bolus; ?>

: KVO; ?>

: taper; ?>

: program_verified_with; ?>

PHYSICAL ASSESSMENT

: vital_signs; ?>

: vital_signs_measurment; ?>

: cardiovascular; ?>

: cardiovacularNotes; ?>

: RESPIRATORY; ?>

: respiratory_notes; ?>

FOODS/FLUIDS

: foods; ?>

: fluid; ?>

: fluid_intake; ?>

: weight; ?>

: fl_comments; ?>

ENDOCRINE

: endoCrine; ?>

: diabetes; ?>

: bs_comments; ?>

ACTIVITY/REST

: activity_rest; ?>

: musculosketal; ?>

: mus_activity; ?>

Encouraged PROM exercises to extremeties : encourage_p_rom_exa_extrimist; ?>

: ambulatory; ?>

: dependent; ?>

: wheelChair; ?>

: arComment; ?>

PAIN

No Deficit : pain; ?>

: pain_level_assessed; ?>

: pla_type; ?>

: pla_quality; ?>

: relief_from; ?>

SKIN

: skin; ?>

: sk_describe; ?>

: bruises_location; ?>

: surgikal_site; ?>

: wound; ?>

: woundcomment; ?>

CIRCULATION

: circulation; ?>

: edema; ?>

: edema_location; ?>

: peripheral_capilary_refil; ?>

: circulation_status; ?>

: circulationStat_comment; ?>

VENTILATION

No Deficit

At Rest

On Exertion

Cough

Productive

Dry

TRACHEOTOMY CARE

MD Orders

YES

GASTROINTESTINAL

GENITOURINARY

Indwelling

Staight Catheter

HYGINENE

No Deficit

INTEGUMENTARY

NERUOLOGICAL

PSYCHOLOGICAL / EMOTIONAL REACTION

No Deficit

Adequate

Calm

Anxious

Depressed

YES

SKILLS - KNOWLEDGE ASSESSMENT

Include Family

RESPONSE TO THERAPY

Denied

Confirmed

YES

MEDICATION

YES

EQUIPMENT

Waste Disposal

Maintain Clear Pathway

YES

Sterile

Clean

MD Orders

(In Centimeter)

Normal Saline

0.125% Dakins Solution

Algisite-M

4X4 Sterile Gauze

Santyl Ointment

4X4 Sterile Gauze

ExuDry

Derlix

Combine/ABDPad

Paper Tape

ACE Bandage

Hypafix Tape

Unchanged

Healing

Resolved

Deteriorating

YES

Light

Modarate

Heavy

YES

PROGRESS TOWARDS GOALS

(Review HHA Care Plan and advise HHA to report any chages in conditions to nurse. In case of emergency call 911)

YES

(Measured in Degrees fahrenheit)

Risk

Moderate

High

Very High

No Bowel Movement after (X) days

Skilled Nursing Interventions Summary/Follow-UP Plan

LPN

Teacher

Other

YES

(Caregiver Name)

HHA

LPN

PCA

Patient Visit Record

PHYSICAL ASSESSMENT

FOODS/FLUIDS

ENDOCRINE

ACTIVITY/REST

PAIN

SKIN

CIRCULATION

VENTILATION

TRACHEOTOMY CARE

MD Orders

GASTROINTESTINAL

GENITOURINARY

HYGINENE

INTEGUMENTARY

NERUOLOGICAL

PSYCHOLOGICAL / EMOTIONAL REACTION

SKILLS - KNOWLEDGE ASSESSMENT

RESPONSE TO THERAPY

MEDICATION

EQUIPMENT

MD Orders

PROGRESS TOWARDS GOALS

Skilled Nursing Interventions Summary/Follow-UP Plan

Authorities