SKILLED NURSING CLINICAL VISIT NOTE

PATIENT NAME_________________________________________________
VISIT DATE_________________ TIME IN:_______________ TIME OUT:_________
FUNCTIONAL/HOMEBOUND STATUS:__________________________________________________________________________________________________
O Unable to ambulate>______ feet without rest period O Needs assistance with all activities/ambulation
O SOB with exertion/activity O Leaving home requires great and taxing effort
O Requires assist of device and/or another to leave home O Medically restricted to home
O Confusion/Cognitive limitations makes it unsafe to leave home______________________________________________________________

O Aid Name: O Aid respectful of privacy O Frequency of visits ok

O Aid understands Care Plan O Aid respectful of belongings O Length of visits ok
O Direct Supervisory Visit O Indirect Supervisory Visit O Patient’s care needs being met

Case Conference Communication:_________________________________________________________________________________________________________

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Dr. Contacted: oY oN Regarding ______________________________________________________________________________________Verbal Order Written O
Medication Change: oY oN ____________________________________________________________________________________________Verbal Order Written O
D/C Planning discussed: oY oN Comment ___________________________________________________________________________________________________
Patient/C.G. informed of change in: O POC O Service O Goals O Frequency O Payer Source O Other__________________________________

CV PLUM GI GU M/S & NEURO INTEGUM MENTAL OTHER

O Chest Pain O Orthopea O Nausea O Nocturia O Vertigo O Wound O Alert O Nutrition
O Edema O SOB/Dyspnea O Vomiting O Burning/Itch O Headache O DM/Arterial/Stasis O Oriented O Hydration
O Diaphoresis O Cough O Constipation O Freq/Odor O Seizures O Pressure Ulcer O Confused O Wgt______#
O Cyanosis O Wheezes/Rales O Diarrhea O Incontinent O Paresis O Incision O Agitated O Med Compliance
O Pedal Pulses O Diminished O Incontinent O Foley O Tremors O Flushed O Forgetful O Home Safety
O Cap. Refill O O2___L/____ O Ostomy O Patent O Falls O Clammy O Depressed O Bld Gluc
(L) BP___/___ O Resp. ______ O Bwl Sounds O Amp R L Bil O Pallor/Jaundice O Anxious O S/S hypo/ hyper
(R) ____/___ glycemia
O HR _____ O Reg O Irreg O Ent Fdg. Tub O Rash/Itching O Lethargic O PT ________
O Reg O Irreg O O2 Sat ____% O Warm O INR _______
O WNL O WNL O WNL O WNL O WNL O WNL O WNL O WNL

Labs Drawn___________________________________ Site _________________________________ Results Called/Faxed to Dr._____________________________

Wound: Location(s)___________________________________________________ Size: L___________ W ___________ D___________ Stage____________

Drainage: Color________________ Consistency_________________ Odor________________ Amount ______________ Change since last visit__________________
Surrounding Tissue: Color___________________________________ Temperature _________________________ Edema__________________________________

Objective Findings/Skilled Interventions/Medication Administration: ___________________________________________________________________________

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Pain: ___/10 Pain Relief Taught: O Take Pain Medications PRN/Ordered O Heat O Cold O Location________________________________
O Pain decrease in intensity O Pain decrease in frequency O Pain treatments(s) effective O Pain treatments not effective, MD notified
Current Pain Medications(s):_______________________________________________________________________________________________________________

Teaching: O Diet O Medications O Home Safety O S/S Infection O Wound Care O Other (See Below)
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Pt/Cg Responses to Teaching: O Verbalizes/Demonstrates Understanding of______________________________________________________________________

O Further Instruction(s) needed d/t _____________________________________________ O Other______________________________________________________

Progress Towards Goals:_________________________________________________________________________________________________________________

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Employee Signature:______________________________________________________________________________________________________________________
Patient/Caregiver Signature ________________________________________________________________________________________________________________