Clinical Visit Note

MM slash DD slash YYYY
Patient Name(Required)
Time In
:
Time Out
:
Homebound Reason:(Required)
Reason for Visit:(Required)

ASSESSMENT, OBSERVATIONS & VISIT RECORD

PATIENT STATUS

Vital Signs

Reassessment

NEUROSENSORY

NEUROSENSORY

NEUROSENSORY
CARDIOVASCULAR
Residual weakness Lack endurance
Other_2
Requires assist to ambulate
Confusion unable to leave home
Severe SOB SOB on exertion
Unable safety leave home unassisted
Dependent adaptive device
Medical Restrictions
Other
Reassessed
Oriented
Arrhythmia
Disoriented
Alert
Bradycardia
Vis Impair
Tachycardia
Agitated_2
Cooperative
Chest Pain
Verbal
Confused
HOH
Dizziness
Peripheral Pulses
Tremors
Paralysis
Edema
Seizures
Agitated
Other_4
Forgetful
Lethargic
Other_3
Urgency
ColostomyIleostomy
Frequency
Abd Pain
Dialysis
Hematoma
Constipation
Odor
Hematuria
PEGFeeding Tube
Venous
Traumatic
Arterial
Polyuria
Abdominal Distention
Incontinence_2
Diarrhea
Diabetic
Pressure
Surgical
NauseaVomiting
Incontinence
Catheter
Size
Other_7
Other_6
Other_5
Unstageable
IV
III
II
I
undefined_11
undefined_13
Diabetes
toggle_126
ADA
Cardiac
Regular
undefined_14
undefined_12
Other_8
Tunneling
undefined_17
undefined_20
undefined_18
undefined_19
Rash
Fever
Turgor
Bloody
SerousSanguineous
Pallor
Flushing
Serous
Sanguineous
Rales
Crackles
Clear
Wound See Wound Care Performed
undefined_21
undefined_22
Ronchi
Wheeze
Course
Other_9
Reddened
Intact
SOB DOE
Other_10
Dry
NA_2
Productive
Intermittent
Persistent
NA_5
NA
Present See Below
Traumatic_2
Arterial_2
Venous_2
NA_3
undefined_26
LUE
RUE
Diabetic_2
Surgical_2
Pressure_2
LLE
RLE
Other_12
O2
NA_4
Safety
GaitBalance
Weakness
Intermittent_2
Continuous
Other_11
III_2
Unstageable_2
IV_2
II_2
I_2
Eschar
Necrotic
Granulation
Slough
Tunneling_2
LPN
HHA
Yes_3
No_3
undefined_31
undefined_32
undefined_29
undefined_30
Follows Care Plan
Universal precautions utilized
Select all that apply
SerousSanguineous_2
Bloody_2
Follows Std Precaution
Sanguineous_2
Serous_2
Perform Care Properly
undefined_33
undefined_34
Patient Satisfied
Intact_2
Reddened_2
OtherAdditional Notes
Other_14
NA_6
Aseptic
Sterile
Vashe
Other_15
NSS
Dakins
NA_7
Acquacel Ag
Meplilex
Acquacel
Betadine
Duoderm
Santyl
Medihoney
Xeroform
Polymem
Other_19
NA_8
Wet to Dry
Betadine Gauze
Other_16
Gauze
ABD Pad
Other_17
Kling
Tape
Tegaderm
Bordered Dressing
Other_18
NA_9
Black
White
Intermittent Suction
Constant Suction
Pressure_3
Cannister Changed
Approx Drainage in Canister
Color
Decreased
Increased
Unchanged
Worsened
Improved
Unchanged_2
Plan of Care Review
Physician Follow Up
Skilled Observation Assessment
Disease Process
Wound CareIncision Care
Pain Management
Infection SS
Infection Control Measures
Complications to Report
IMSubQ Injection
Bleeding Precautions
Oxygen Safety
Ostomy Care
Foley Care
Tube FeedCare
Medication regime actions side effects on
Other_20
Patient CG verbalizeddemonstrated understanding of instructions provided
With paindiscomfort
Without paindiscomfort
With expressed interest
Patient tolerating medications without side effects or adverse reactions
NA_10
Wound Care
Medication Management
Woundincision healing
IV Therapy
NA Not Independent due to
Physical Limitations
Cognitive Limitations
No Available Cg
Other_21
Yes Explanation
No Explanation
Interdisciplinary Team
Patient
Doctor
Cg
Discharge
PlanGoal for Next visit
Verbal Orders obtained
NA_11
Interdisciplinary CommunicationCollaboration
NA_12
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