Clinical Visit Note
Date
(Required)
MM slash DD slash YYYY
Patient Name
(Required)
First
Last
SN Name Discipline
Time In
Hours
:
Minutes
AM
PM
AM/PM
Time Out
Hours
:
Minutes
AM
PM
AM/PM
Homebound Reason:
(Required)
Bedbound
Confusion, unable to leave home
Dependent, adaptive device:
Medical Restrictions
Requires assist. for all activities
Requires assist. to ambulate
Residual weakness / Lack endurance
Severe SOB / SOB on exertion
Unable safely leave home unassisted
Other
Reason for Visit:
(Required)
Assessment
Teaching/Training
W/C
Other
ASSESSMENT, OBSERVATIONS & VISIT RECORD
PATIENT STATUS
Vital Signs
Weight
Temp
PU
BP
Resp
Pain Intensity
1
2
3
4
5
6
7
8
9
10
Pain Location
Pain Description
Reassessment
Reassessed
NEUROSENSORY
NEUROSENSORY
NEUROSENSORY
Oriented
Vis. Impair
Verbal
Tremors
Agitated
Other
CARDIOVASCULAR
Arrhythmia
Tachycardia
Dizziness
Edema
Other
Bradycardia
Chest Pain
Peripheral Pulses
Edima
Other:
Peripheral Pulses
Signature
Image Hopper
Residual weakness Lack endurance
First Choice
Second Choice
Third Choice
Nursing DX Problem
Other_2
First Choice
Second Choice
Third Choice
Requires assist to ambulate
First Choice
Second Choice
Third Choice
Confusion unable to leave home
First Choice
Second Choice
Third Choice
Severe SOB SOB on exertion
First Choice
Second Choice
Third Choice
Unable safety leave home unassisted
First Choice
Second Choice
Third Choice
Dependent adaptive device
First Choice
Second Choice
Third Choice
Medical Restrictions
First Choice
Second Choice
Third Choice
undefined_3
undefined
undefined_2
Other
First Choice
Second Choice
Third Choice
Wt
Temp
BP
Pu
Resp
Location
Description
Reassessed
First Choice
Second Choice
Third Choice
Oriented
First Choice
Second Choice
Third Choice
Arrhythmia
First Choice
Second Choice
Third Choice
Disoriented
First Choice
Second Choice
Third Choice
Alert
First Choice
Second Choice
Third Choice
Bradycardia
First Choice
Second Choice
Third Choice
Vis Impair
First Choice
Second Choice
Third Choice
Tachycardia
First Choice
Second Choice
Third Choice
Agitated_2
First Choice
Second Choice
Third Choice
Cooperative
First Choice
Second Choice
Third Choice
Chest Pain
First Choice
Second Choice
Third Choice
Verbal
First Choice
Second Choice
Third Choice
Confused
First Choice
Second Choice
Third Choice
HOH
First Choice
Second Choice
Third Choice
Dizziness
First Choice
Second Choice
Third Choice
Peripheral Pulses
First Choice
Second Choice
Third Choice
undefined_4
04
Tremors
First Choice
Second Choice
Third Choice
Paralysis
First Choice
Second Choice
Third Choice
Edema
First Choice
Second Choice
Third Choice
Seizures
First Choice
Second Choice
Third Choice
undefined_5
Agitated
First Choice
Second Choice
Third Choice
Other_4
First Choice
Second Choice
Third Choice
Forgetful
First Choice
Second Choice
Third Choice
Lethargic
First Choice
Second Choice
Third Choice
undefined_6
Other_3
First Choice
Second Choice
Third Choice
Urgency
First Choice
Second Choice
Third Choice
ColostomyIleostomy
First Choice
Second Choice
Third Choice
Frequency
First Choice
Second Choice
Third Choice
Abd Pain
First Choice
Second Choice
Third Choice
Dialysis
First Choice
Second Choice
Third Choice
Hematoma
First Choice
Second Choice
Third Choice
Constipation
First Choice
Second Choice
Third Choice
Odor
First Choice
Second Choice
Third Choice
Hematuria
First Choice
Second Choice
Third Choice
PEGFeeding Tube
First Choice
Second Choice
Third Choice
Venous
First Choice
Second Choice
Third Choice
Traumatic
First Choice
Second Choice
Third Choice
Arterial
First Choice
Second Choice
Third Choice
Polyuria
First Choice
Second Choice
Third Choice
Abdominal Distention
First Choice
Second Choice
Third Choice
Incontinence_2
First Choice
Second Choice
Third Choice
Diarrhea
First Choice
Second Choice
Third Choice
Diabetic
First Choice
Second Choice
Third Choice
Pressure
First Choice
Second Choice
Third Choice
Surgical
First Choice
Second Choice
Third Choice
undefined_7
NauseaVomiting
First Choice
Second Choice
Third Choice
Incontinence
First Choice
Second Choice
Third Choice
Catheter
First Choice
Second Choice
Third Choice
Size
First Choice
Second Choice
Third Choice
undefined_10
Other_7
First Choice
Second Choice
Third Choice
undefined_8
undefined_9
Other_6
First Choice
Second Choice
Third Choice
Other_5
First Choice
Second Choice
Third Choice
Venous Arterial Traumatic Surgical Pressure Diabetic OtherL x W x D
Unstageable
First Choice
Second Choice
Third Choice
IV
First Choice
Second Choice
Third Choice
III
First Choice
Second Choice
Third Choice
II
First Choice
Second Choice
Third Choice
I
First Choice
Second Choice
Third Choice
Eschar Necrotic Slough Granulation
undefined_11
First Choice
Second Choice
Third Choice
undefined_13
First Choice
Second Choice
Third Choice
Diabetes
First Choice
Second Choice
Third Choice
toggle_126
First Choice
Second Choice
Third Choice
ADA
First Choice
Second Choice
Third Choice
Cardiac
First Choice
Second Choice
Third Choice
Regular
First Choice
Second Choice
Third Choice
undefined_14
First Choice
Second Choice
Third Choice
undefined_12
First Choice
Second Choice
Third Choice
Base
Blood Sugar per pt
undefined_15
Other_8
First Choice
Second Choice
Third Choice
undefined_16
Tunneling
Yes
No
undefined_17
First Choice
Second Choice
Third Choice
undefined_20
First Choice
Second Choice
Third Choice
undefined_18
First Choice
Second Choice
Third Choice
undefined_19
First Choice
Second Choice
Third Choice
Scant Mod Copious None
Rash
First Choice
Second Choice
Third Choice
Fever
First Choice
Second Choice
Third Choice
Turgor
First Choice
Second Choice
Third Choice
Bloody
First Choice
Second Choice
Third Choice
SerousSanguineous
First Choice
Second Choice
Third Choice
Pallor
First Choice
Second Choice
Third Choice
Flushing
First Choice
Second Choice
Third Choice
Serous
First Choice
Second Choice
Third Choice
Sanguineous
First Choice
Second Choice
Third Choice
Rales
First Choice
Second Choice
Third Choice
Crackles
First Choice
Second Choice
Third Choice
Clear
First Choice
Second Choice
Third Choice
Wound See Wound Care Performed
First Choice
Second Choice
Third Choice
Yes No
undefined_21
First Choice
Second Choice
Third Choice
undefined_22
First Choice
Second Choice
Third Choice
Ronchi
First Choice
Second Choice
Third Choice
Wheeze
First Choice
Second Choice
Third Choice
Course
First Choice
Second Choice
Third Choice
undefined_23
Other_9
First Choice
Second Choice
Third Choice
Reddened
First Choice
Second Choice
Third Choice
Intact
First Choice
Second Choice
Third Choice
SOB DOE
First Choice
Second Choice
Third Choice
undefined_24
Other_10
First Choice
Second Choice
Third Choice
Dry
First Choice
Second Choice
Third Choice
NA_2
First Choice
Second Choice
Third Choice
Productive
First Choice
Second Choice
Third Choice
Intermittent
First Choice
Second Choice
Third Choice
Persistent
First Choice
Second Choice
Third Choice
NA_5
First Choice
Second Choice
Third Choice
NA
First Choice
Second Choice
Third Choice
Present See Below
First Choice
Second Choice
Third Choice
undefined_25
Traumatic_2
First Choice
Second Choice
Third Choice
Arterial_2
First Choice
Second Choice
Third Choice
Venous_2
First Choice
Second Choice
Third Choice
NA_3
First Choice
Second Choice
Third Choice
undefined_26
First Choice
Second Choice
Third Choice
ADL DEFICIT
1
LUE
First Choice
Second Choice
Third Choice
RUE
First Choice
Second Choice
Third Choice
Diabetic_2
First Choice
Second Choice
Third Choice
Surgical_2
First Choice
Second Choice
Third Choice
Pressure_2
First Choice
Second Choice
Third Choice
2
1_2
LLE
First Choice
Second Choice
Third Choice
RLE
First Choice
Second Choice
Third Choice
undefined_27
Other_12
First Choice
Second Choice
Third Choice
LM
O2
First Choice
Second Choice
Third Choice
NA_4
First Choice
Second Choice
Third Choice
Venous Arterial Traumatic Surgical Pressure Diabetic OtherL x W x D_2
Safety
First Choice
Second Choice
Third Choice
GaitBalance
First Choice
Second Choice
Third Choice
Weakness
First Choice
Second Choice
Third Choice
Intermittent_2
First Choice
Second Choice
Third Choice
Continuous
First Choice
Second Choice
Third Choice
2_2
Other_11
First Choice
Second Choice
Third Choice
III_2
First Choice
Second Choice
Third Choice
Unstageable_2
First Choice
Second Choice
Third Choice
IV_2
First Choice
Second Choice
Third Choice
II_2
First Choice
Second Choice
Third Choice
I_2
First Choice
Second Choice
Third Choice
Other_13
Eschar
First Choice
Second Choice
Third Choice
Necrotic
First Choice
Second Choice
Third Choice
Granulation
First Choice
Second Choice
Third Choice
Slough
First Choice
Second Choice
Third Choice
Base_2
undefined_28
Tunneling_2
Yes_2
No_2
LPN
First Choice
Second Choice
Third Choice
HHA
First Choice
Second Choice
Third Choice
Yes_3
First Choice
Second Choice
Third Choice
No_3
First Choice
Second Choice
Third Choice
undefined_31
First Choice
Second Choice
Third Choice
undefined_32
First Choice
Second Choice
Third Choice
undefined_29
First Choice
Second Choice
Third Choice
undefined_30
First Choice
Second Choice
Third Choice
Scant Mod Copious None_2
Follows Care Plan
First Choice
Second Choice
Third Choice
Universal precautions utilized
No_4
No_5
No_6
No_7
Select all that apply
Yes_4
Yes_5
Yes_6
Yes_7
SerousSanguineous_2
First Choice
Second Choice
Third Choice
Bloody_2
First Choice
Second Choice
Third Choice
Follows Std Precaution
First Choice
Second Choice
Third Choice
Sanguineous_2
First Choice
Second Choice
Third Choice
Serous_2
First Choice
Second Choice
Third Choice
Perform Care Properly
First Choice
Second Choice
Third Choice
Yes No_2
undefined_33
First Choice
Second Choice
Third Choice
undefined_34
First Choice
Second Choice
Third Choice
Patient Satisfied
First Choice
Second Choice
Third Choice
undefined_35
Intact_2
First Choice
Second Choice
Third Choice
Reddened_2
First Choice
Second Choice
Third Choice
OtherAdditional Notes
First Choice
Second Choice
Third Choice
undefined_36
Other_14
First Choice
Second Choice
Third Choice
1_3
Explanation for No answers 1
2_3
3
Explanation for No answers 2
NA_6
First Choice
Second Choice
Third Choice
Wound Care Frequency
Aseptic
First Choice
Second Choice
Third Choice
Sterile
First Choice
Second Choice
Third Choice
Technique
Vashe
First Choice
Second Choice
Third Choice
Other_15
First Choice
Second Choice
Third Choice
NSS
First Choice
Second Choice
Third Choice
Dakins
First Choice
Second Choice
Third Choice
NA_7
First Choice
Second Choice
Third Choice
Acquacel Ag
First Choice
Second Choice
Third Choice
Meplilex
First Choice
Second Choice
Third Choice
Acquacel
First Choice
Second Choice
Third Choice
Betadine
First Choice
Second Choice
Third Choice
Duoderm
First Choice
Second Choice
Third Choice
undefined_37
Santyl
First Choice
Second Choice
Third Choice
Medihoney
First Choice
Second Choice
Third Choice
Xeroform
First Choice
Second Choice
Third Choice
Polymem
First Choice
Second Choice
Third Choice
Other_19
First Choice
Second Choice
Third Choice
1_4
NA_8
First Choice
Second Choice
Third Choice
Wet to Dry
First Choice
Second Choice
Third Choice
Betadine Gauze
First Choice
Second Choice
Third Choice
Other_16
First Choice
Second Choice
Third Choice
2_4
Gauze
First Choice
Second Choice
Third Choice
ABD Pad
First Choice
Second Choice
Third Choice
Other_17
First Choice
Second Choice
Third Choice
Kling
First Choice
Second Choice
Third Choice
3_2
Tape
First Choice
Second Choice
Third Choice
Tegaderm
First Choice
Second Choice
Third Choice
Bordered Dressing
First Choice
Second Choice
Third Choice
Other_18
First Choice
Second Choice
Third Choice
NA_9
First Choice
Second Choice
Third Choice
Black
First Choice
Second Choice
Third Choice
White
First Choice
Second Choice
Third Choice
Intermittent Suction
First Choice
Second Choice
Third Choice
Constant Suction
First Choice
Second Choice
Third Choice
mmHg
Pressure_3
First Choice
Second Choice
Third Choice
Cannister Changed
First Choice
Second Choice
Third Choice
undefined_38
mL
Approx Drainage in Canister
First Choice
Second Choice
Third Choice
Color
First Choice
Second Choice
Third Choice
Decreased
First Choice
Second Choice
Third Choice
Increased
First Choice
Second Choice
Third Choice
Unchanged
First Choice
Second Choice
Third Choice
Worsened
First Choice
Second Choice
Third Choice
Improved
First Choice
Second Choice
Third Choice
Unchanged_2
First Choice
Second Choice
Third Choice
Progress from last visit Other
Subjective Objective Observations
1_5
2_5
3_3
4
Intervention Teaching
Plan of Care Review
First Choice
Second Choice
Third Choice
Physician Follow Up
First Choice
Second Choice
Third Choice
Skilled Observation Assessment
First Choice
Second Choice
Third Choice
Disease Process
First Choice
Second Choice
Third Choice
Wound CareIncision Care
First Choice
Second Choice
Third Choice
Pain Management
First Choice
Second Choice
Third Choice
Infection SS
First Choice
Second Choice
Third Choice
Infection Control Measures
First Choice
Second Choice
Third Choice
Complications to Report
First Choice
Second Choice
Third Choice
IMSubQ Injection
First Choice
Second Choice
Third Choice
Bleeding Precautions
First Choice
Second Choice
Third Choice
Oxygen Safety
First Choice
Second Choice
Third Choice
Ostomy Care
First Choice
Second Choice
Third Choice
Foley Care
First Choice
Second Choice
Third Choice
Tube FeedCare
First Choice
Second Choice
Third Choice
fill_15
Medication regime actions side effects on
First Choice
Second Choice
Third Choice
undefined_39
Other_20
First Choice
Second Choice
Third Choice
Interventions Teaching 1
Interventions Teaching 2
Interventions Teaching 3
Patient CG verbalizeddemonstrated understanding of instructions provided
First Choice
Second Choice
Third Choice
With paindiscomfort
First Choice
Second Choice
Third Choice
Without paindiscomfort
First Choice
Second Choice
Third Choice
With expressed interest
First Choice
Second Choice
Third Choice
Patient tolerating medications without side effects or adverse reactions
First Choice
Second Choice
Third Choice
Description_2
Other Response
NA_10
First Choice
Second Choice
Third Choice
Wound Care
First Choice
Second Choice
Third Choice
Medication Management
First Choice
Second Choice
Third Choice
Woundincision healing
First Choice
Second Choice
Third Choice
IV Therapy
First Choice
Second Choice
Third Choice
NA Not Independent due to
First Choice
Second Choice
Third Choice
Physical Limitations
First Choice
Second Choice
Third Choice
Cognitive Limitations
First Choice
Second Choice
Third Choice
No Available Cg
First Choice
Second Choice
Third Choice
Other_21
First Choice
Second Choice
Third Choice
Goals Plan Collaboration
Patient Progress Toward Goals
Yes Explanation
First Choice
Second Choice
Third Choice
Discharge Process Discussed with
No Explanation
First Choice
Second Choice
Third Choice
Interdisciplinary Team
First Choice
Second Choice
Third Choice
Patient
First Choice
Second Choice
Third Choice
Doctor
First Choice
Second Choice
Third Choice
Cg
First Choice
Second Choice
Third Choice
undefined_40
Discharge
First Choice
Second Choice
Third Choice
PlanGoal for Next visit
First Choice
Second Choice
Third Choice
undefined_41
Verbal Orders obtained
First Choice
Second Choice
Third Choice
NA_11
First Choice
Second Choice
Third Choice
undefined_42
Interdisciplinary CommunicationCollaboration
First Choice
Second Choice
Third Choice
NA_12
First Choice
Second Choice
Third Choice
SN Signature
Patient Signature
Untitled
First Choice
Second Choice
Third Choice
Post Custom Field