60 Day Summary Template

Please select only fields that are applicable on this form and then submit. None of the information is mandatory on this template.

Pain
Pain over the episode has been
- none.
- well-controlled with no exacerbation.
- moderately controlled with on and off episodes of exacerbation.
- Poorly controlled and unresolved with severe exacerbation
Neuropathy over the episode has been
- well-controlled with no exacerbation.
- moderately controlled with on and off episodes of exacerbation.
- Poorly controlled and unresolved with severe exacerbation
Pain variation over the episode on a scale of 0-10
Patient’s goals with pain during the episode were
- met
- partially met
- unmet
Respiratory Status
Dyspneic status over the episode has
- been stable, with no acute exacerbation of SOB.
- improved with better exercise tolerance.
- deteriorated with acute episodes of SOB on minimal exertion.
Symptoms of Asthma/COPD have been
- well-controlled with no exacerbation.
- moderately controlled with on and off episodes of exacerbation.
- Poorly controlled and unresolved with severe exacerbation
Integumentary Status
Skin Integrity/Wounds
- No risk for skin integrity noted over the episode.
- Patient did not develop any wound during the episode.
- Patient developed during the episode.
- Patient had wound when the episode started.
- Wound care continued over the episode.
- Wound(s) healed completely and wound care was discontinued during the episode.
- Wound care continues with wound(s) partially healed.
Please specify wounds patient developed during the episode
Please specify wounds patient had when the episode started.
Endocrine Status
Blood sugars over the episode have been
- well-controlled.
- moderately controlled.
- Poorly controlled.
Blood sugars over the episode varied between
Cardiovascular Status
Blood pressure over the episode has been
- well controlled
- moderately controlled
- poorly controlled
Symptoms of CHF over the episode have been
- well controlled
- moderately controlled
- poorly controlled
Systolic blood pressure varied between
Diastolic blood pressure varied between
Heart rate varied between
GU/GI
Bowel movements frequency over the episode
- regular
- occasional slowdown
- irregular with increased frequency of constipation
Constipation has been
- well-controlled with no exacerbation.
- moderately controlled with on and off episodes of bowel slowdown.
- Poorly controlled with exacerbation
Symptoms of GERD have been
- well-controlled with no exacerbation.
- moderately controlled with on and off episodes of dyspepsia and heartburn.
- Poorly controlled with exacerbation
Symptoms of BPH have been
- well-controlled with no exacerbation.
- moderately controlled with on and off episodes of urinary retention and difficulty initiating stream of urine.
- Poorly controlled with exacerbation
Episodes of urinary incontinence have been
- well-controlled with no exacerbation.
- moderately controlled with on and off accidents and wetting.
- Poorly controlled with exacerbation
Episodes of bowel incontinence have been
- well-controlled with no exacerbation.
- moderately controlled with on and off accidents.
- Poorly controlled with exacerbation
Nutrition
Appetite over the episode has
- been stable.
- progressively diminished.
- abruptly diminished.
- progressively improved.
Neuro/Emotional/Behavioral Status
Alertness and orientation over the episode has
- WNL.
- Stable with no gross exacerbation of confusion and disorientation.
- moderately compromised with on and off episodes of confusion and disorientation.
- severely compromised with exacerbation of confusion and disorientation episodes.
Musculoskeletal Status
Muscle strength over the episode has
- WNL.
- been stable with no deterioration.
- progressively diminished.
- Showed a quick decline.
- progressively improved.
Compliance with Assistive device
- compliant with use of assistive device.
- partially compliant with use of assistive device.
- Noncompliant with use of assistive device.
Falls
- no falls.
- uneventful falls.
- eventful falls.
Number of fall(s)
Compliance with Medications/Dietary Recommendations
Compliance with medications
- compliance
- partial compliance
- noncompliance
Compliance with dietary recommendations
- compliance
- partial compliance
- noncompliance
Medication Changes/Allergies/Infections
Did any medication changes happened over the episode?
- Yes
- No
Medication changes/dose changes happened over the episode for better management of
- HTN ;
- CHF ;
- Arrhythmia ;
- Hypotension ;
- Diabetes Mellitus ;
- Pain ;
- Asthma ;
- COPD ;
- Chronic Bronchitis ;
- Peptic Ulcer Disease ;
- Constipation ;
- GERD ;
- BPH;
- Urinary Retention ;
- Urinary Incontinence ;
Other conditions for which medication changes/dose changes happened over the episode
Allergies over the episode
- no seasonal allergies
- flare-up of seasonal allergies
Did patient present with any infections over the episode?
- Yes
- No
Infections over the episode
- sinus/respiratory infection ;
- wound infection ;
- UTI ;
Other infections
New Diagnosis/Therapy/ER&Hospitalization Visits
Did patient have new diagnosis over the episode?
- Yes
- No
Patient had new diagnosis of
Therapy
- was recommended.
- goals were met and discharged.
- goals were partially met.
- to continue.
- HEP established.
Did patient have ER visits/hospitalization over the episode?
- Yes
- No
Patient had ER/hospitalization for

Please select only fields that are applicable on this form and then submit. None of the information is mandatory on this template.

60 Day Summary Template

Pain

Respiratory Status

Integumentary Status

Endocrine Status

Cardiovascular Status

GU/GI

Nutrition

Neuro/Emotional/Behavioral Status

Musculoskeletal Status

Compliance with Medications/Dietary Recommendations

Medication Changes/Allergies/Infections

New Diagnosis/Therapy/ER&Hospitalization Visits