Recertification Template

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

Patient's Health History
Select As Applicable
Cardiovascular Conditions
- HTN ;
- Hypotension ;
- CHF ;
- Tachycardia ;
- Bradycardia ;
- Cardiac arrhythmia ;
- Valvular abnormality ;
- Cardiomyopathy ;
- Peripheral vascular disease ;
- Myocardial infarction ;
- Coronary artery disease ;
Blood Disorders
- Deep venous Thrombosis ;
- Pulmonary emboli ;
- Anemia ;
Pulmonary Conditions
- Asthma ;
- Seasonal allergies ;
- COPD ;
- Emphysema ;
- Chronic bronchitis ;
Endocrine Conditions
- Diabetes Mellitus Type 1 ;
- Diabetes Mellitus Type 2 ;
- Hypothyroidism ;
- Hyperparathyroidism ;
Integumentary Conditions
- Pressure ulcer ;
- Diabetic wound ;
- Surgical wounds ;
Gastrointestinal Conditions
- Constipation ;
- Diarrhea ;
- Bowel incontinence ;
- Nausea and vomiting ;
- GERD ;
- Crohn’s disease ;
- Diverticulitis ;
- Cirrhosis ;
- Gall stones ;
Genitourinary Conditions
- BPH ;
- Renal stones ;
- Renal failure ;
- Dialysis ;
- Urinary incontinence ;
- Frequent UTIs ;
Neuro/Emotional Conditions
- Anxiety ;
- Depression ;
- Schizophrenia ;
- Alzheimer’s ;
- Seizures ;
Musculoskeletal Conditions
- Muscle weakness ;
- Multiple falls ;
- Muscle spasms ;
- Multiple sclerosis ;
- Parkinson’s disease ;
- Cerebrovascular accident ;
- Hemiplegia ;
- Paraplegia ;
- Fibromyalgia ;
- Osteoarthritis ;
- Rheumatoid arthritis ;
- Gout ;
Cancers
- Prostate cancer ;
- Breast cancer ;
- Skin cancer ;
- Colon cancer ;
Miscellaneous
- Glaucoma ;
- Cataracts ;
- Vertigo ;
- Smoking ;
- Alcoholism ;
- Drug abuse ;
- poor vision ;
- diminished hearing ;
Patient's Surgical History
- Right mastectomy ;
- Left mastectomy ;
- Colectomy ;
- Partial colectomy ;
- Partial gastrectomy ;
- Colostomy ;
- Cholecystectomy ;
- Prostatectomy ;
- TURP ;
- Renal stones removal ;
- Bladder excision ;
- Urostomy ;
- Stent placement ;
- Pacemaker insertion ;
- AICD placement ;
- Valve replacement ;
- Cardiac ablation ;
- Right knee replacement ;
- Left knee replacement ;
- Right hip replacement ;
- Left hip replacement ;
- Cervical fusion ;
- Lumbar fusion ;
- ORIF ;
- Amputation ;
- C-section ;
- Total hysterectomy ;
- Cataract removal ;
- Organ transplant ;
Patient's Additional Health History
- Pain Information
- Select As Applicable
- Does patient complain of pain?
  - Yes
  - No
- No Pain Information
  - Patient has no complaint of pain.
  - Pain is not a concern for the patient any day during the episode
  - Patient takes OTC pain medications, only as needed.
  - Occasional low grade pain reported.
- Pain range if patient complains of occasional low grade pain (number only)
- Pain type
  - continuous
  - on and off
- Pain grade
  - low grade
  - moderate grade
  - severe grade
- Reason for pain
  - gout ;
  - multiple sclerosis ;
  - rheumatoid arthritis ;
  - neuropathy ;
  - osteoarthritis ;
  - slipped disc ;
  - spinal stenosis ;
  - post-surgery ;
  - Other
- Other reasons for pain
- Pain site
  - weight bearing joints ;
  - diffuse body ;
  - small joints in extremities ;
  - upper back ;
  - lower back ;
  - wound site ;
  - Other
- Other pain site
- Pain exacerbation factors
  - weight bearing ;
  - ambulation ;
  - inflamed joints ;
  - diffuse muscle spasms ;
  - contractures ;
  - Other
- Other pain exacerbation factors
- Pain Management
  - Patient takes pain medications, only on an as needed basis.
  - Patient does not want to take any pain medications.
  - Patient has no prescription pain medications, but takes OTC pain medications.
  - Patient is on multiple medications for pain management.
  - Patient would consider alternative pain management strategies for pain control.
- Does patient take any pain medications on a regular basis?
  - Yes
  - No
- No Pain Medications
  - Patient does not want to take any pain medications.
  - Patient has no prescription pain medications, but takes OTC pain medications.
  - Patient takes pain medications, only on an as needed basis.
  - Patient would consider alternative pain management strategies for pain control during the episode.
- Pain Medications
  - Tylenol ;
  - Tramadol ;
  - Percocet ;
  - Norco ;
  - Tylenol # 3 ;
  - Fentanyl patch every 72 hours ;
  - Oxycontin ;
  - Hydrocodone ;
  - Ibuprofen ;
  - Meloxicam ;
  - Celebrex ;
  - Diclofenac ;
  - Naproxen ;
  - Prednisone ;
  - Hydrocortisone ;
  - Other
- Additional Pain Medications
- Recent Changes with Pain Medications
  - No new pain medications are added during the episode.
  - No dose changes happened with pain medications during the episode.
  - Patient was started on pain medications during the episode.
  - Patient's dose of pain medications was changed during the episode.
  - Patient was recently discontinued on pain medications.
- Reasons for Dose Changes with Pain Medications
  - achieving goal on pain control;
  - side-effects from the medication;
  - allergic response;
  - Other
- Other Reasons for Dose Changes with Pain Medications
- Reasons for Discontinuation of Pain Medications
  - achieving goal on pain control;
  - side-effects from the medication;
  - allergic response;
  - Other
- Other Reasons for Discontinuation of Pain Medications
- Side Effects of Pain Medications
  - none ;
  - nausea ;
  - vomiting ;
  - constipation ;
  - dizziness ;
  - confusion ;
  - difficulty breathing ;
  - Other
- Additional Side Effects
- Please specify recent pain variation on a scale of 0-10 (number only)
- Pain Level Today on a scale of 0-10 (number only)
- Does patient complain of neuropathy?
  - Yes
  - No
- Neuropathy has been
  - recent complaint ;
  - chronic complaint ;
- Neuropathy Exacerbation
  - stable, with no exacerbation.
  - exacerbated lately.
- Location of Neuropathy
  - RLE ;
  - LLE ;
  - BLE ;
  - RUE ;
  - LUE ;
  - BUE ;
  - Other
- Please specify other location for Neuropathy
- Neuropathy Exacerbation Factors
  - poor control of blood sugars ;
  - relapse of multiple sclerosis ;
  - progression of disc degeneration ;
  - pinched nerves in the spine ;
  - peripheral vascular disease ;
  - poor blood supply to the distal extremities ;
  - chemotherapy ;
  - chronic smoking ;
  - Other
- Other factors for exacerbation of neuropathy
- Antineuropathy medications (name only)
- Changes with Antineuropathy Medications
  - No new antineuropathy medications are added during the episode.
  - No dose changes happened with antineuropathy medications during the episode.
  - Patient was started on antineuropathy medications during the episode.
  - Patient's dose with antineuropathy medications was changed recently.
  - Patient was discontinued on antineuropathy medications during the episode.
- Reasons for Dose Changes with Antineuropathy Medications
  - achieving goal on neuropathy control;
  - side-effects from the medication;
  - allergic response;
  - Other
- Other Reasons for Dose Changes with Antineuropathy Medications
- Reasons for Discontinuation of Antineuropathy Medications
  - achieving goal on neuropathy control;
  - side-effects from the medication;
  - allergic response;
  - Other
- Other Reasons for Discontinuation of Antineuropathy Medications
- Pain control response
  - well controlled
  - moderately controlled
  - poorly controlled
- Goals for Pain Management
  - Patient wants pain to be completely resolved and managed at 0 on a scale of 0 – 10.
  - Patient wants pain to be managed between 0 – 5, with no exacerbation beyond 6, on a scale of 0 – 10.
  - Patient wants to have the pain managed at a max of 2 – 3 on a scale of 0 – 10.
  - Patient wants to prevent any acute exacerbation of pain from happening.
  - Pain is well-controlled and patient has no goals with regards to pain management.
- Additional Information-Pain
- Respiratory Status
- Select As Applicable
- Breath sounds are clear and vesicular in
  - left apex ;
  - right apex ;
  - left base ;
  - right base ;
  - all chest areas
- Breath sounds are diminished in
  - left apex ;
  - right apex ;
  - left base ;
  - right base ;
  - all chest areas
- Does the patient present with any additional breath sounds?
  - Yes
  - No
- Rhonchi heard
  - left apex ;
  - right apex ;
  - left base ;
  - right base ;
  - all chest areas
- Crepitations heard
  - left apex ;
  - right apex ;
  - left base ;
  - right base ;
  - all chest areas
- Wheezing
  - left apex ;
  - right apex ;
  - left base ;
  - right base ;
  - all chest areas
- Breath Sounds Over the Episode
  - No compromise noted with breath sounds over the episode.
  - Breath sounds continued to be shallow and diminished during the episode.
  - Wheezing heard prominently over the episode, secondary to history of asthma/COPD.
  - Crepitations heard prominently over the episode, secondary to increased fluid retention in the chest.
- Chest Expansion
  - Chest expansion is even and symmetrical bilaterally.
  - No issue reported by the patient regarding chest expansion during the episode.
  - Uneven and asymmetrical chest expansion have been consistent findings over the episode.
  - Chest expansion is limited.
- Reasons for Limited Chest Expansion
  - scoliosis involving thoracic spine ;
  - multiple sclerosis ;
  - recurrent episodes of pneumonia ;
  - atelectasis ;
  - other
- Other reasons for limited chest expansion
- Does the patient complain of cough?
  - Yes
  - No
- Dry Cough
  - Patient presents with dry cough currently.
  - Patient reports dry cough for the last 2 days.
  - Patient’s continued smoking contributes to episodes of cough.
  - On and off episodes of dry cough were noted during the certification period.
- Productive Cough
  - Patient presents with productive cough currently.
  - Patient reports the cough started out dry and gradually turned productive, in the last 24 hours.
  - Patient presented with episode(s) of productive cough during the certification period
  - Patient’s continued smoking contributes to episodes of cough.
- Sputum production amount
  - mild to moderate amount
  - abundant amount
- Sputum color
  - white colored
  - dark yellow colored
  - green colored
- Cough Exacerbation Factors
  - cold weather ;
  - smoking ;
  - seasonal allergies ;
  - other
- Other cough exacerbation factors
- Cough Relief Measures
  - Patient uses benzonatate for control of cough.
  - Patient uses an OTC cough suppressant, as needed, for control of cough.
  - Patient uses mucinex for control of cough and relief from chest congestion.
  - Patient is currently on a course of antibiotics for control of the chest infection.
  - Patient was on a course of antibiotics over the episode for control of the productive cough and infection control.
- Response to Relief Measures
  - Patient reports the cough to have gotten better in the last 2 days.
  - Response to cough relief measures was partial during the episode.
  - Patient responded favorably to the cough relief measures during the episode.
  - Patient reports cough to have worsened in the last 24 hours.
  - Patient’s poor response to relief measures was reported to the physician.
  - Unrelieved cough with exacerbation of SOB contributed to an ER visit and hospitalization during the episode.
- Sore Throat and Nasal Congestion
  - Patient presents with sore throat and nasal congestion currently.
  - Patient presented with episodes of sore throat and nasal congestion during the certification period.
  - Patient reports worsening symptoms of sore throat and nasal congestion for the last 2 days.
  - Patient reports symptoms of sore throat and nasal congestion for the last one week, which reportedly got better in the last 2 days.
- Smoking
  - Patient has been a chronic smoker.
  - Patient has been a smoker, on and off, for last 15 – 20 years.
  - Patient was a smoker before, but currently is compliant with smoking cessation.
  - Patient is noncompliant with smoking cessation instructions.
  - Patient’s noncompliance with inhalation medications led to exacerbation of COPD episodes and pulmonary infections.
- Does the patient have history of Asthma/COPD?
  - Yes
  - No
- Patient has history of
  - bronchial asthma ;
  - emphysema ;
  - chronic bronchitis ;
  - COPD
- Triggers for asthma and COPD
  - Environmental allergens ;
  - Physical exercise ;
  - Occupational irritants ;
  - Cold weather ;
  - Smoking ;
  - other
- Other triggers for asthma and COPD
- Does the patient use any bronchodilators/inhalers/nebulizer?
  - Yes
  - No
- Current medications for bronchodilation and relief of COPD symptoms (name only)
- Compliance bronchodilator Inhalations/nebulizer?
  - compliance
  - partial compliance
- Is patient independent with using bronchodilator Inhalations/nebulizer?
  - is independent
  - needs caregiver assistance
  - needs instructions
- Recent changes with inhalation medications
  - no changes happened with inhalation medications.
  - dose changes happened with inhalation medications.
  - new inhalation medications are added.
- Is patient/caregiver informative regarding pursed lip breathing?
  - Yes
  - No
- Compliance regarding pursed lip breathing?
  - compliance
  - noncompliance
  - partial compliance
- Dyspnea and Exacerbation of SOB
  - No acute exacerbation of dyspnea was reported in recent times.
  - Dyspnea is reportedly moderately controlled in recent times and patient stayed SOB on moderate exertion, without any acute exacerbation.
  - Episodes of acute exacerbation of dyspnea happened during the certification period.
  - Worsening of congestive heart failure led to exacerbation of dyspnea during the episode.
  - Recurrent episodes of COPD in recent times contributed to episodes of exacerbation of SOB lately.
  - Patient’s noncompliance with smoking cessation contributed to exacerbation of dyspneic episodes.
  - Patient’s noncompliance with inhalation medications led to exacerbation of dyspneic episodes.
- Endurance
  - WNL
  - partially compromised
  - moderately compromised
  - severely compromised
- Does the patient have any recent history of sinus/chest infection?
  - Yes
  - No
- Sinus Infections
  - Patient has history of frequent sinus infections.
  - No exacerbation of sinus infections was reported lately.
  - Patient had an episode of sinus infection with nasal congestion and drainage over the certification period.
  - Patient currently has an episode of sinus infection.
  - Patient’s history of unresolved sinus drainage and infections contributed to recurrent pulmonary infections lately.
  - Exacerbation of sinus infections in recent times led to an ER visit and hospitalization during the episode.
- Chest Infections
  - Patient has history of frequent pulmonary infections.
  - No exacerbation of pulmonary infections was noted during the episode.
  - Patient had an episode of pneumonia during the certification period.
  - Patient’s chest infection has completely resolved during the episode.
  - Patient’s chest infection is yet unresolved.
  - Patient’s noncompliance with smoking cessation leads to frequent pulmonary infections.
  - Patient’s history of recurrent and unresolved pulmonary infections led to an in-patient stay lately.
- Antibiotics Course
  - Patient was on IV antibiotics, through a PICC line.
  - Patient was on oral antibiotics until recently.
  - Patient was also on Methylprednisolone Dose Pak.
  - Patient is currently on IV antibiotics, administered via a PICC line.
  - Patient is currently on IV antibiotics, administered via a central port.
  - Patient is currently on oral antibiotics for the infection reported.
  - Patient is also on Methylprednisolone Dose Pak currently.
- Flu Shots
  - No vaccination history is available.
  - Patient does not believe in vaccinations.
  - Patient did not receive flu shot yet, for the current season.
  - Patient was instructed upon having the flu shot done.
  - Caregiver was instructed upon having the patient receive flu shot for the season.
  - Patient received the flu shot for this season.
- Pneumonia Shots
  - No vaccination history is available.
  - Patient’s pneumonia shot is up-to-date and currently, is covered.
  - Patient does not believe in vaccinations.
  - Patient is currently not covered for pneumonia.
  - Patient was instructed upon having the pneumonia shot done.
  - Caregiver was instructed upon having the patient receive pneumonia shot.
  - Patient’s pneumonia shot is updated during the episode.
- Does patient have a history of seasonal allergies?
  - Yes
  - No
- Seasonal Allergies
  - Patient has history of seasonal allergies, with no recent activation reported.
  - Patient has history of seasonal allergies, with on and off episodes of activation noted during the certification period.
  - Patient currently has an activation of seasonal allergies and is on oral antihistamines for the same.
  - Patient is on regular antihistamine intake for management and preventing activation of symptoms of seasonal allergies.
  - Patient takes antihistamines, as needed, for managing activation of symptoms of seasonal allergies.
  - Caregiver was instructed upon having the patient receive pneumonia shot.
- Allergy symptoms resolution
  - resolved
  - unresolved
  - gradually improving
- Is patient Oxygen dependent?
  - Yes
  - No
- Oxygen Use in LPM
  - 2
  - 2.5
  - 3
  - 3.5
- Frequency of Oxygen Use
  - continuous
  - intermittent
- Recent changes with oxygen administration
  - Yes
  - No
- Dose changes with Oxygen (Example- 3LPM to 5 LPM)
- Is patient independent with Oxygen use?
  - Yes
  - No
- Is patient/caregiver informative regarding Oxygen precautions and safety?
  - Yes
  - No
- Nasal and oral mucus membranes appearance
  - moist
  - dry
- Reasons for Oxygen Need
  - Patient’s COPD status necessitates patient being on supplemental oxygen.
  - Worsening of COPD status contributed to increase in the dose of oxygen lately.
  - Patient’s CHF status necessitates patient being on supplemental oxygen.
  - Deteriorating CHF symptoms contributed to increase in the dose of oxygen lately.
  - Recurrent nasal and chest infections during the episode necessitates the patient being on supplemental oxygen.
  - No dose changes with Oxygen use happened over the episode.
- Additional Information-Respiratory Status
- Integumentary Status
- Select As Applicable
- Skin Turgor
  - fair
  - poor
  - age appropriate
- Color of Skin
  - pink and healthy
  - pale
  - blue and cyanotic
  - yellow and jaundiced
- Color of Mucous Membranes
  - pink and healthy
  - pale
  - blue and cyanotic
  - yellow and jaundiced
- Hydration Status of Oral Mucosa
  - dry
  - moist
- Skin Temperature
  - Skin temperature was WNL and warm to touch.
  - Distal extremities were felt warm to touch.
  - Distal extremities were felt cold to touch.
- Location of Cold Distal Extremities
  - RUE;
  - LUE;
  - BUE;
  - RLE;
  - LLE;
  - BLE;
- Toe Nails Appearance
  - trimmed.
  - grown.
- Podiatrist Visit
  - Patient has no regular podiatrist visits.
  - Patient has regular visits to the podiatrist’s office for toe nail care.
  - No visit with podiatrist reported in recent times.
  - A scheduled visit with podiatrist is soon coming up.
  - Patient/caregiver was recommended to schedule visit with the podiatrist during the episode.
  - RN trimmed the toe nails today.
  - Patient/caregiver to be instructed upon measures to care for toe nails.
- Does the patient have any active wound?
  - Yes
  - No
- History of the Wound
  - This is a chronic wound and wound care has been continuing over the episode.
  - Patient developed the wound during this episode and wound care has been continuing.
- The wound is located on
- Type of Wound
  - surgical wound.
  - surgical incision.
  - diabetic wound.
  - pressure necrosis wound.
  - pressure ulcer.
  - abrasion wound.
  - burn wound.
  - laceration wound.
  - avulsion wound.
  - mechanical injury.
  - wound suffered from fall.
  - drain insertion site.
  - arterial ulcer.
  - venous ulcer.
  - stasis ulcer.
  - nonstageable pressure ulcer.
- Pressure Ulcer Stage (number only)
- Independence with Wound Care
  - Patient is independent at performing wound care and is trained on the same.
  - Patient can be independent with wound care and needs to be trained.
  - Patient is dependent on caregiver assistance for wound dressing change.
  - Caregiver is independent at performing wound care and is trained on the same.
  - Caregiver can be independent with wound care, but needs to be trained.
  - No willing caregiver is available to perform regular wound dressing change.
  - Home health staff to perform wound dressing, as ordered.
- Was wound care performed today?
  - Yes
  - No
- No Wound Care Today
  - Today is not a scheduled wound care day and the old dressing was noted to be intact during the visit.
  - Caregiver has already changed the dressing for today.
  - SN did not perform wound dressing change today and wound measurements are unknown.
  - Wound care orders are not available.
  - Other
- Other reasons for not performing wound care today
- Hand Washing and Old Dressing Removal
  - SN performed hand washing with soap and water before doing the dressing change. Gloves were worn.
  - Old dressing on the wound was removed and discarded according to OSHA guidelines.
  - Old dressing on the wound site reportedly came loose.
  - The wound site was uncovered, with no dressing noted.
- Drainage amount on old dressing
  - No noticeable
  - Mild
  - Moderate
  - Heavy
- Drainage type on old dressing
  - serous
  - serosanguineous
  - sanguineous
  - mucous
  - purulent
- Any foul smell noted?
  - Foul smell
  - No foul smell
- The wound is
  - open wound
  - closed wound
- The wound edges are approximated with
  - staples
  - sutures
  - glue
  - zipline
- Wound Bed Appearance
  - Wound bed appeared pink in color and healthy.
  - Healthy granulation tissue deposition noted on the surface of wound bed.
  - Yellow brown slough noted on the wound bed.
  - Wound bed appeared black in color and necrotic.
  - The wound is partially scabbed.
- Periwound area appearance
  - pink and healthy
  - pale
  - dry and scaly
  - blue and cyanotic
- Erythema in surrounding tissue
  - No noticeable
  - Mild
  - Moderate
  - Severe
- Swelling of the wound site
  - No noticeable
  - Mild
  - Moderate
  - Severe
- Wound Cleanser Used
  - sterile normal saline
  - vashe
  - dermal wound cleanser
  - betadine solution
  - Dakin’s solution
- Drying the Wound Site and Surrounding Skin
  - The wound site and surrounding skin were gently blot dried using 4 x 4.
- Wound Measurements
  - Wound measurements were taken using sterile Q-tips.
  - Wound was poorly circumscribed and so, difficult to measure.
  - Multiple clusters of wounds noted and are difficult to measure.
- Incision Line Measurements
- Wound Measurements (dimensions)
- Tunneling (For example- 4 cm in 3’o clock position)
- Undermining (For example- 2'o clock to 8'o clock position)
- Skin Prep Application
  - Skin prep was applied to prevent damage of the surrounding skin by adhesives.
- Please specify antibacterial ointment applied (name only)
- Was wound vac fixed today?
  - Yes
  - No
- Primary Wound Dressing
  - 4x4 ;
  - sterile gauze ;
  - bordered gauze ;
  - promogran ;
  - moist hydrofera blue ;
  - xeroform gauze dressing ;
  - aquacel silver ;
  - mepilex dressing ;
  - suresite ;
  - transparent film dressing ;
  - Telfa ;
  - Other
- Other primary wound dressing
- Wound Packing
  - sterile gauze ;
  - promogran ;
  - moist hydrofera blue ;
  - xeroform gauze ;
  - aquacel silver ;
  - Iodoform packing gauze ;
  - sorbact ribbon ;
  - Calcium Alginate ;
  - Collagen ;
  - Other
- Other wound packing
- Secondary Wound Dressing
  - 4x4 ;
  - sterile gauze ;
  - bordered guaze ;
  - promogran ;
  - moist hydrofera blue ;
  - xeroform gauze ;
  - aquacel silver ;
  - Calcium Alginate ;
  - Mepilex silver ;
  - Mepilex foam dressing ;
  - Heel foam ;
  - Medihoney ;
  - Hydrogel dressing ;
  - Hydrocolloid dressing ;
  - Suresite ;
  - Transparent film dressing ;
  - Telfa ;
  - Other
- Other secondary wound dressing
- Tertiary Wound Dressing
  - 4x4 ;
  - sterile gauze ;
  - bordered guaze ;
  - promogran ;
  - moist hydrofera blue ;
  - xeroform gauze ;
  - aquacel silver ;
  - Calcium Alginate ;
  - Mepilex silver ;
  - Mepilex foam dressing ;
  - Heel foam ;
  - Medihoney ;
  - Hydrogel dressing ;
  - Hydrocolloid dressing ;
  - Suresite ;
  - Transparent film dressing ;
  - Telfa ;
  - Other
- Other tertiary wound dressing
- Securing the Wound Dressing
  - paper tape ;
  - medipore tape ;
  - Kerlix roll ;
  - ACE wrap ;
  - coban ;
  - compression wraps ;
  - Other
- Other wound securing material
- Wound Vac Dressing Change Summary
  - Sterile foam was packed into the wound site. Foam is secured in place with a layer of tegaderm. A hole was cut into tegaderm and drainage tube was attached to it. This was further secured with tegaderm to prevent any leaks. The other end of drainage tube was connected to the pump and pump was restarted. No alerts or alarms noted.
- Wound Vac Pressure in mm Hg (number only)
- Canister drainage amount
  - No noticeable
  - Mild
  - Moderate
  - Heavy
- Canister drainage type
  - serous
  - serosanguineous
  - sanguineous
  - mucous
  - purulent
- Amount of canister drainage in ml (number only)
- Was canister changed today?
  - Yes
  - No
- Any signs and symptoms of wound infection noted today?
  - Yes
  - No
- Pain level reported by patient during the wound care (number only)
- Additional Information-Integumentary Status
- Endocrine Status
- Select As Applicable
- Is patient prediabetic/diabetic?
  - Yes
  - No
- Prediabetes
  - Patient is a prediabetic and is not on any active medications for blood sugar control.
  - Blood sugars are being closely watched.
  - Patient was recommended weight loss of 10% body weight and patient has been working on the same.
  - Patient was recommended 20 minutes of moderate intensity daily physical exercise, to help manage blood sugars better.
- History of diabetes
  - chronic
  - recently turned
- Type of diabetes
  - type 1
  - type 2
- Did patient turn diabetic during the certification episode?
  - Yes
  - No
- Is patient currently taking any medications for diabetes?
  - Yes
  - No
- Patient is currently on
  - oral antidiabetics
  - insulin
- Oral Antidiabetics
  - Patient has been on oral antidiabetic medications for long time.
  - Patient/caregiver reports no changes with regards to oral antidiabetic medications/doses during the episode.
  - Patient was started on oral antidiabetics during the episode for better management of blood sugars.
  - Patient's dose of antidiabetics was changed recently.
  - Patient was discontinued on oral antidiabetic medications during the episode.
- Reasons for Dose Changes with Oral Antidiabetics
  - poor therapeutic response;
  - patient’s weight gain;
  - patient’s weight loss;
  - poorly controlled blood sugars;
  - episodes of hyperglycemia;
  - episodes of hypoglycemia;
  - bothersome side-effects;
  - allergic response;
  - Other
- Other Reasons for Dose Changes with Oral Antidiabetics
- Reasons for Discontinuation with Oral Antidiabetics
  - poor therapeutic response;
  - patient’s weight gain;
  - patient’s weight loss;
  - poorly controlled blood sugars;
  - episodes of hyperglycemia;
  - episodes of hypoglycemia;
  - bothersome side-effects;
  - allergic response;
  - Other
- Other Reasons for Discontinuation with Oral Antidiabetics
- Current oral antidiabetic medications (name only)
- Insulin
  - Patient has been chronically dependent on insulin for blood sugar control.
  - Patient/caregiver reports no changes with regards to insulin and doses during the episode.
  - Patient was started on insulin for better management of blood sugars during the episode.
  - Patient's dose with insulin was changed recently.
  - Patient was discontinued on insulin recently.
- Reasons for Dose Changes with Insulin
  - poor therapeutic response;
  - patient’s weight gain;
  - patient’s weight loss;
  - poorly controlled blood sugars;
  - episodes of hyperglycemia;
  - episodes of hypoglycemia;
  - bothersome side-effects;
  - allergic response;
  - Other
- Other Reasons for Dose Changes with Insulin
- Reasons for Discontinuation with Insulin
  - poor therapeutic response;
  - patient’s weight gain;
  - patient’s weight loss;
  - poorly controlled blood sugars;
  - episodes of hyperglycemia;
  - episodes of hypoglycemia;
  - bothersome side-effects;
  - allergic response;
  - Other
- Other Reasons for Discontinuation with Oral Insulin
- Current Insulin (name only)
- Is patient independent with insulin administration?
  - Yes
  - No
- Reasons for Patient’s Dependence on Caregiver Assistance with Insulin Administration
  - poor vision ;
  - poor cognition ;
  - hand tremors ;
  - compromised dexterity ;
  - Other
- Other Reasons for Patient’s Dependence on Caregiver Assistance with Insulin Administration
- Compliance with medication intake
  - compliance
  - partial compliance
  - noncompliance
- Blood sugar control
  - well controlled
  - moderately controlled
  - fairly controlled
  - poorly controlled
- Hemoglobin A1c
  - No recent information is available on HbA1c.
  - Patient’s most recent HbA1c was in normal limits, indicating decent blood sugar control in recent times.
  - Patient’s most recent HbA1c was elevated, indicating poor blood sugar control in recent times.
- Patient’s most recent HbA1c in % (number only)
- Is patient independent with regards to checking blood sugar?
  - Yes
  - No
- Reasons for Patient’s Dependence on Caregiver Assistance with Blood Sugar Check
  - poor vision ;
  - poor cognition ;
  - hand tremors ;
  - compromised dexterity ;
  - Other
- Other reasons for patient’s dependence on caregiver assistance with blood sugar check
- Compliance with regards to checking and log maintenance of every day blood sugars
  - compliance
  - partial compliance
  - noncompliance
- Is patient's blood sugar reading abnormal during today's visit?
  - Yes
  - No
- Elevated Blood Sugars Levels during the Visit
  - Patient’s blood sugars were noted to be high today, during the time of visit.
  - Patient reports compliance with medication intake, as ordered.
  - Elevated blood sugars are secondary to noncompliance with dietary recommendations.
  - Patient presented with trouble concentrating and fatigue during the visit.
  - Patient forgot taking morning dose of antidiabetic medications today.
  - SN administered the medication today.
  - Patient reports having taken the medication, just a while ago.
  - The blood sugars settled, after 45 minutes of taking the medication.
- Low Blood Sugar Levels during the Visit
  - Patient’s blood sugar reading was noted to be low.
  - Patient forgot to eat the breakfast today.
  - The patient skipped meal today.
  - Patient was compliant with medication intake though, which contributed to low blood sugars.
  - Patient was mildly confused and disoriented during the visit.
  - SN served quick snack for the patient.
  - The blood sugars settled, after 45 minutes of nutrition intake.
- Report to Physician
  - Blood sugar reading was reported to the physician.
  - Patient was noted to be stable and oriented when SN left.
  - Caregiver was available to follow-up with the patient.
- Dietary Recommendations
  - Patient was lately recommended low calorie ADA diet.
  - Patient has chronic history of being on low calorie ADA diet.
- ADA diet - number of calories recommended (Only number)
- Knowledge of diabetic foot and nail care
  - Patient/caregiver is poorly informative regarding diabetic foot and nail care.
  - Patient/caregiver is informative regarding diabetic foot and nail care.
  - Patient/caregiver need to be instructed on this topic over the episode.
  - SN instructed the patient/caregiver regarding foot and nail care.
- Independence with diabetic foot and nail care
  - Patient is independent with foot examination and nail care.
  - Patient is dependent on caregiver assistance with foot examination and nail care.
  - No willing caregiver is available for regular foot and nail care.
  - HHA performs regular foot and nail care.
  - SN performs regular foot and nail care.
- Compliance with daily foot examination and toe nail care
  - compliance
  - partial compliance
  - noncompliance
- Does patient have history of diabetic foot ulcers?
  - Yes
  - No
- No Diabetic Foot Ulcers
  - No active diabetic wounds noted on bilateral feet currently.
  - Patient has no history of diabetic foot ulcers.
- Current diabetic wound location
- Past diabetic wound location
- Past amputation location
- Current Risk for Skin Integrity and Toe Nails
  - No active risk for skin integrity was noted on bilateral feet currently.
  - No ingrown toe nails are noted currently.
  - Ingrown toe nails were noted on bilateral feet.
  - SN trimmed toe nails on the patient during the visit.
- Podiatrist Visit
  - Patient does not see a podiatrist.
  - Patient has regular visits to podiatrist.
  - Patient had a visit to the podiatrist lately.
  - No recent podiatrist visit reported.
  - Patient was referred for a podiatrist visit by PCP.
  - Patient was instructed regarding compliance with regular podiatrist visits.
- Does the patient have history of diabetic neuropathy?
  - Yes
  - No
- Diabetic Neuropathy
  - Nerve pain in the extremities has been a recent complaint during the episode.
  - Neuropathy in the extremities has been a chronic complaint.
  - Nerve pain is secondary to poorly managed diabetes.
- Neuropathy Symptoms
  - Patient reports sensitivity to touch, temperature, and pain in the extremities to be intact.
  - Sensitivity to touch, temperature, and pain is compromised in the involved extremities.
- Location of Neuropathy
  - RUE;
  - LUE;
  - BUE;
  - RLE;
  - LLE;
  - BLE;
- Neuropathy Exacerbation
  - Patient’s neuropathy in the involved extremities has worsened lately, with the patient complaining of increasing burning sensation, tingling and numbness.
  - Patient reports sensitivity to touch, temperature, and pain in the extremities to be intact.
  - Sensitivity to touch, temperature, and pain is compromised in the involved extremities.
- Current Antinueropathy Medication (name only)
- Recent Changes with Antineuropathy Medications
  - Patient has been on medications for control of neuropathy.
  - Patient/caregiver reports no recent changes with regards to antineuropathy medication and doses during the episode.
  - Patient was started on medications for control of neuropathy during the episode.
  - Patient's dose with antineuropathy medications was changed recently.
  - Patient was discontinued on antineuropathy medications during the episode.
- Reasons for Dose Changes with Antineuropathy Medications
  - goals met;
  - poor therapeutic response;
  - improved control of neuropathy;
  - worsening dizziness;
  - poorly controlled blood sugars;
  - episodes of hyperglycemia;
  - bothersome side-effects
  - allergic response;
  - Other
- Other Reasons for Dose Changes with Antineuropathy Medications
- Reasons for Discontinuation with Antineuropathy Medications
  - goals met;
  - poor therapeutic response;
  - improved control of neuropathy;
  - worsening dizziness;
  - poorly controlled blood sugars;
  - episodes of hyperglycemia;
  - bothersome side-effects
  - allergic response;
  - Other
- Other Reasons for Discontinuation with Antineuropathy Medications
- Does the patient have history of diabetic nephropathy?
  - Yes
  - No
- Diabetic Nephropathy
  - No issues were reported regarding the patient’s renal function.
  - Patient’s renal function reportedly has been WNL.
  - Nephropathy, secondary to poorly controlled blood sugars, has been a recent complaint during this episode.
  - Patient has history of nephropathy, secondary to chronic poorly managed diabetes.
- Exacerbation of Nephropathy
  - Patient’s nephropathy has been stable during the episode, with no exacerbation reported.
  - No recent information is available on the patient’s compromised renal function.
  - Nephropathy has worsened in recent times.
  - Patient has been started on dialysis during the episode, due to worsening CKD.
  - Patient has been chronically dialysis dependent.
- Does the patient have any complaint with thyroid?
  - Yes
  - No
- Patient has complaint with
  - Hypothyroidism
  - Hyperthyroidism
  - Thyroid cancer
  - Other
- Other complaints related to thyroid
- Hypothyroidism
  - Patient has history of hypothyroidism.
  - Patient was lately diagnosed with hypothyroidism during the episode.
  - Currently, patient is on hormone supplementation.
- Exacerbation of Hyporthyroidism?
  - Yes
  - No
- No Exacerbation of Hypothyroidism
  - No changes with activity and appetite reported during the episode.
  - No dose changes with thyroid hormone supplementation reported in this episode.
- Exacerbation of Hypothyroidism
  - Diminishing activity and appetite reported lately.
  - Caregiver reports changes in patient’s voice in recent times.
  - Findings of goiter were reported to the physician.
  - Dose changes with thyroid hormone supplementation happened lately.
  - Response to dose changes is being evaluated.
  - Patient reports improvement in the symptoms of hypothyroidism with dose change on hormone supplementation.
- Hyperthyroidism
  - Patient has history of hyperthyroidism.
  - Patient was diagnosed with hyperthyroidism during the episode.
  - No goiter noted on examination during the episode.
  - No changes with voice reported over the recertification period.
  - Findings of goiter with enlarged thyroid noted on examination over the recertification period.
  - Caregiver reports changes in patient’s voice over the recertification period.
  - Patient underwent partial thyroidectomy during the episode.
  - Patient is actively not on any medication currently.
  - Patient is currently on medications for management of hyperthyroidism.
- Exacerbation of Hyperthyroidism?
  - Yes
  - No
- Symptoms of Exacerbation of Hyperthyroidism
  - palpitations ;
  - tachycardia ;
  - excessive hunger ;
  - mood swings ;
  - fatigue ;
  - irritability ;
  - restlessness ;
  - panic attacks ;
  - insomnia ;
  - irregular menstruation ;
  - tremors ;
  - Other
- Symptoms of Exacerbation of Hyperthyroidism
- Current Medications for Managing Hyperthyroidism
  - methimazole;
  - propylthiouracil;
  - radioactive iodine ;
  - Other
- Other Medications for Management of Hyperthyroidism
- Recommendations for Managing Exacerbation of Hyperthyroidism
  - changes with the medication ;
  - partial thyroidectomy ;
  - radioactive iodine ;
  - Other
- Recommendations for Managing Exacerbation of Hyperthyroidism
- Thyroid Cancer
  - Patient has history of thyroid cancer.
  - Patient underwent partial thyroidectomy over the recertification period.
  - Patient is currently on thyroid hormone supplementation to cover for the deficiency.
- Findings of goiter
  - No goiter noted on examination
  - No changes with patient’s voice reported lately.
  - Findings of goiter with enlarged thyroid noted on examination over the recertification period.
  - Caregiver reports changes in patient’s voice in recent times.
- Additional Information-Endocrine Status
- Cardiovascular Status
- Select As Applicable
- Is patient borderline hypertensive/hypertensive?
  - Yes
  - No
- Borderline Hypertension
  - Patient is a borderline hypertensive.
  - Patient is not on any medications currently.
  - Blood pressures are being closely watched.
- Hypertension
  - Patient is a chronic hypertensive.
  - Patient was diagnosed with hypertension during the episode.
  - Patient progressed from borderline hypertension to hypertension over the episode.
- Recent Changes with Antihypertensive Medications
  - Patient has been medications for management of hypertension.
  - Patient was started on antihypertensive medications during the episode.
  - Patient is not on any medications currently.
  - Patient/caregiver reports no recent changes with regards to antihypertensive medications/doses.
  - Patient's dose with antihypertensive medications was changed lately.
  - Patient was discontinued on antihypertensive medications during the episode.
- Reasons for Dose Changes with Antihypertensive Medications
  - poor therapeutic response;
  - poorly controlled edema;
  - episodes of worsening dizziness;
  - tachycardia;
  - bradycardia;
  - hypotensive episodes;
  - bothersome side-effects;
  - allergic response;
  - Other
- Other Reasons for Dose Changes with Antihypertensive Medications
- Reasons for Discontinuation with Antihypertensive Medications
  - poor therapeutic response;
  - poorly controlled edema;
  - episodes of worsening dizziness;
  - tachycardia;
  - bradycardia;
  - hypotensive episodes;
  - bothersome side-effects;
  - allergic response;
  - Other
- Other Reasons for Discontinuation with Antihypertensive Medications
- Current Antihypertensive Medications (name only)
- Blood pressure control recently
  - decently managed
  - mild to moderately elevated
  - poorly controlled
  - elevated
  - low with increase in hypotensive episodes.
- Stroke and Hospitalization
  - Patient has history of an episode of stroke, secondary to poorly managed HTN.
  - Patient had one episode of suspected stroke recently, but was ruled out on evaluation.
  - Patient had one episode of stroke during the certification period, secondary to poorly managed HTN.
  - Patient had an ER visit and hospitalization during this episode, secondary to poorly managed HTN.
- Patient’s independence with blood pressure monitoring
  - independent with blood pressure monitoring.
  - dependent upon caregiver assistance for blood pressure monitoring.
- Compliance with antihypertensive medications
  - compliance
  - partial compliance
  - noncompliance
- Compliance with daily blood pressure reading and log maintenance
  - compliance
  - partial compliance
  - noncompliance
- Does patient complain of any hypotensive episodes?
  - Yes
  - No
- Hypotensive Episodes
  - Patient’s blood pressure readings have been on the lower side during the episode.
  - Patient has history of orthostatic hypotension and reports episodes of dizziness and confusion with sudden change in position.
  - Patient reports on and off episodes of dizziness, secondary to low blood pressure numbers during the episode.
  - Blood pressure readings are being closely watched.
- Recent Changes to Hypotensive Medications
  - Patient was discontinued on antihypertensive medications during the episode, for better control of blood pressure readings.
  - Dose of antihypertensive medication was reduced lately, for better control of hypotensive symptoms.
  - Patient’s dose of diuretics was decreased during the episode, for better management of hypotensive episodes.
- Blood pressure monitoring to be avoided on
  - LUE ;
  - RUE ;
  - LLE ;
  - RLE ;
- Reasons for Limitations Regarding Site of BP Recording
  - mastectomy ;
  - location of shunt ;
  - lymph node removal ;
  - Other
- Other Reasons for Limitations Regarding Site of BP Recording
- Was blood pressure abnormal during the visit today?
  - Yes. Blood pressure was elevated.
  - Yes. Blood Pressure was low.
  - No. Blood pressure was normal.
- Elevated Blood Pressure During the Visit
  - Blood pressure reading was elevated today, during the time of SN visit.
  - Noncompliance with dietary recommendations contribute to elevated BP numbers.
  - Patient forgot taking dose of antihypertensive medications.
  - RN administered antihypertensive medication today during the visit.
  - Patient reports having taken the medication, just a while ago.
  - Blood pressure was noted to be stable, 30 minutes after taking the medication, when RN left.
  - Patient’s elevated blood pressure numbers were reported to the physician.
  - Caregiver was available for follow-up.
- Low Blood Pressure During the Visit
  - Patient presented with hypotension today, during the time of SN visit.
  - Patient appeared stable, with no symptoms of low BP.
  - Patient reported mild confusion and dizziness, secondary to the low BP numbers.
  - Patient reports compliance with antihypertensive medication intake.
  - Patient reportedly overdosed on antihypertensive medication, leading to hypotension.
  - Patient’s sudden change in position could have contributed to low BP numbers.
  - Patient’s noncompliance with fluid intake recommendations could have contributed to low BP numbers.
  - RN administered 2 cups of water.
  - Patient was allowed to sit stable for 30 minutes, before another reading on BP was taken.
  - Blood pressure was noted to be WNL, when RN left.
  - Patient reported improvement with confusion and dizziness reported. Caregiver was available for follow-up.
  - Patient’s low blood pressure numbers were reported to the physician.
- Normal Heart Rate
  - No issues noted with patient’s heart rate during the episode.
  - Heart rate was reported to be in normal limits during the episode.
- Altered Heart Rate
  - Patient has chronic history of tachycardia and is on medication for management of the same.
  - Patient was diagnosed with tachycardia during the episode and was started on medication for management of the same.
  - Patient presented with elevated heart rate over the episode, probably secondary to the low BP numbers during the episode.
  - Patient’s heart rate usually is on the lower side, secondary to good vagal tone.
  - Patient has chronic history of bradycardia.
  - Patient has been presenting with episodes of bradycardia and dizziness during the certification period.
  - Patient’s blood pressure and heart rate are currently being closely monitored.
- Patient’s heart rate over the episode varied between
- Heart Rate Over the Episode
  - Heart rate over the episode has been within normal limits defined on the plan of care.
  - Heart rate during the episode was occasionally elevated.
  - Over the episode, heart rate was mostly closer to the upper limit defined on the plan of care.
  - Heart rate during the episode was occasionally low.
  - Over the episode, heart rate was mostly closer to the lower limit defined on the plan of care.
- Does patient have history of CHF?
  - Yes
  - No
- Congestive Heart Failure
  - Patient has history of chronic CHF and is on medications for management.
  - Patient was diagnosed with CHF during the episode, with medication changes for managing the same.
- CHF management
  - decently managed
  - mild to moderately managed
  - poorly managed
- Symptoms of CHF
  - dizziness ;
  - headache ;
  - increased frequency and exacerbation of episodes of SOB ;
  - compromised endurance ;
  - fluid retention ;
  - Other
- Other Symptoms of CHF
- Is patient taking any medications for CHF?
  - Yes
  - No
- Current medications for CHF (name only)
- Recent Medication Changes for CHF
  - Patient has been on CHF medications for some time.
  - Patient/caregiver reports no changes with regards to medications/doses for managing symptoms of heart failure during the episode.
  - Patient was started on new medication during the episode for management of symptoms of CHF exacerbation.
  - Patient’s dose of CHF medications was changed in recent times.
  - Patient was discontinued with CHF medications recently.
- Reasons for Dose Changes with CHF Medications
  - poor therapeutic response;
  - increasing shortness of breath;
  - poorly controlled edema;
  - episodes of worsening dizziness;
  - tachycardia;
  - bradycardia;
  - increased fluid back-up in the chest;
  - hypotensive episodes;
  - bothersome side-effects;
  - allergic response;
  - Other
- Other Reasons for Dose Changes with CHF Medications
- Reasons for Discontinuation with CHF Medications
  - poor therapeutic response;
  - increasing shortness of breath;
  - poorly controlled edema;
  - episodes of worsening dizziness;
  - tachycardia;
  - bradycardia;
  - increased fluid back-up in the chest;
  - hypotensive episodes;
  - bothersome side-effects;
  - allergic response;
  - Other
- Other Reasons for Discontinuation with CHF Medications
- Potassium Supplementation
  - Patient has history of hypokalemia, secondary to Lasix intake and so, is on potassium supplement, to prevent any cardiac abnormalities.
  - Patient was diagnosed with hypokalemia during the episode, secondary to Lasix intake and so, was started on potassium supplementation.
  - No changes were made with the dose of potassium supplement lately.
  - Changes with regards to dose of potassium supplement happened during the episode.
  - Patient is being closely monitored for the effects of potassium on cardiac function.
- Does the patient have any complaint of fluid retention?
  - Yes
  - No
- Pedal Edema and Fluid Retention in Recent Times
  - Patient presented with no episodes of pedal edema during the certification period.
  - Patient presented with on and off episodes of pedal edema during the episode.
  - Pedal edema has been more consistent finding during the episode.
  - Patient presents with low – moderate grade edema consistently throughout the episode.
  - Intensity of edema and fluid retention have progressively increased during the episode.
  - Deterioration of edema status was reported to the physician.
- Pedal Edema during the Visit Today (number only)
- Exacerbation Factors for Pedal Edema
  - poor compliance with recommendations on heart healthy diet ;
  - noncompliance with dialysis schedule ;
  - exacerbation of heart failure ;
  - Exacerbation of COPD in recent times ;
  - Other
- Other Exacerbation Factors for Pedal Edema
- Does the patient have any limitations on fluid intake?
  - Yes
  - No
- Reasons for Patient's Limitations on Fluid Intake
  - heart failure ;
  - renal failure ;
  - dialysis dependency ;
  - Other
- Other Reasons for Patient's Limitations on Fluid Intake
- Fluid Volume Limitations in liter (number only)
- Knowledge Regarding Fluid Volume Limitations
  - knowledgable
  - poorly knowledgable
- Compliance Regarding Fluid Volume Limitations
  - compliance
  - moderate compliance
  - poor compliance
- Weight Changes in Recent Times
  - Patient could not be weighed during the episode, due to patient’s poor balance and high fall risk.
  - Patient could not be weighed during the episode, due to patient’s bedbound status.
  - Over the episode, weight recordings during weekly SN visits were stable, with no gross changes.
- Abrupt Weight Gain in lb (number only)
- Does patient have history of arrhythmia?
  - Yes
  - No
- Normal Cardiac Rhythm
  - Patient has no history of cardiac arrhythmias.
  - Over the episode, heart beat was noted to be regular at normal rate.
- History of Arrhythmia
  - Patient has chronic history of arrhythmia.
  - Patient was diagnosed with arrhythmia during the episode.
- Types of Arrhythmia
  - Atrial Flutter ;
  - Atril Fibrillation ;
  - Ventricular Flutter ;
  - Ventricular Fibrillation ;
  - Other
- Other Types of Arrhythmia
- Arrhythmia Management Measures
  - Patient has been on antiarrhythmic medications for management of the arrhythmia.
  - Patient was started on antiarrhythmic medications during the episode, for management of the arrhythmia.
  - Patient has history of defibrillator implantation.
  - Patient has history of undergoing cardioversion.
  - Patient underwent cardioversion during the episode, to restore the cardiac rhythm.
  - Patient has history of pacemaker insertion
  - Patient underwent pacemaker insertion during the episode.
- Current Arrhythmia Medications (name only)
- Recent Changes with Antiarrhythmic Medications
  - Patient has been on medication for management of arrhythmia for long time.
  - Patient/caregiver reports no changes with regards to medications/doses for managing symptoms of arrhythmia during the episode.
  - Patient was started on medication for better control of symptoms of arrhythmia during the episode.
  - Patient's dose with antiarrhythmic medications was changed recently.
  - Patient was discontinued on antiarrhythmic medications recently.
- Reasons for Dose Changes with Antiarrhythmic Medications
  - goals met;
  - poor therapeutic response;
  - uncontrolled tachycardia;
  - poorly controlled bradycardia;
  - increasing shortness of breath;
  - uncontrolled palpitations;
  - episodes of worsening dizziness;
  - hypotensive episodes;
  - bothersome side-effects;
  - allergic response;
  - Other
- Other Reasons for Dose Changes with Antiarrhythmic Medications
- Reasons for Discontinuation with Antiarrhythmic Medications
  - goals met;
  - poor therapeutic response;
  - uncontrolled tachycardia;
  - poorly controlled bradycardia;
  - increasing shortness of breath;
  - uncontrolled palpitations;
  - episodes of worsening dizziness;
  - hypotensive episodes;
  - bothersome side-effects;
  - allergic response;
  - Other
- Other Reasons for Discontinuation with Antiarrhythmic Medications
- No Exacerbation of Arrhythmia
  - Patient’s arrhythmia was decently controlled during the episode, with no exacerbation of symptoms.
  - Patient’s arrhythmia is mild to moderately controlled during the episode.
  - No episodes of chest pain and palpitations reported during the certification period.
  - No changes with regards to antiarrhythmic medications happened during the episode.
- Exacerbation of Arrhythmia
  - Patient’s arrhythmia is poorly controlled during the episode.
  - Patient presented with worsening symptoms of arrhythmia during the episode.
  - Patient presented with increased frequency of episodes of dizziness and confusion during the episode.
  - Patient presented with increased frequency and exacerbation of episodes of SOB, during the episode.
  - No changes with regards to antiarrhythmic medications happened in recent times.
  - Over the episode, changes with regards to antiarrhythmic medications happened, for better control of arrhythmia and management of symptoms.
- Does patient have history of hyperlipidemia?
  - Yes
  - No
- Hyperlipidemia and Elevated Cholesterol
  - Patient has history of hyperlipidemia and atherosclerosis.
  - Patient was diagnosed with hyperlipidemia during the episode.
- No Exacerbation of Hyperlipidemia
  - No recent evaluation of blood cholesterol levels reported during the episode.
  - No recent exacerbation of blood cholesterol levels reported during the episode.
  - Patient presents with moderate exercise tolerance, with no changes during the episode.
- Exacerbation of Hyperlipidemia
  - Patient is a poorly managed hyperlipidemic.
  - Exacerbation of blood cholesterol levels reported during the episode.
  - Patient reports decreased exercise toleranceduring the episode.
- Is patient taking any medications for elevated lipids and cholesterol?
  - Yes
  - No
- Current medications for elevated cholesterol (name only)
- Recent Changes with Hyperlipidemia Medications
  - Patient has been on hyperlipidemia medications for some time.
  - Patient/caregiver reports no changes with regards to antihyperlipidemic medications/doses during the episode.
  - Patient was started on hyperlipidemia medications during the episode.
  - Patient's dose with hyperlipidemia medications was changed recently.
  - Patient was discontinued on hyperlipidemia medications recently.
- Reasons for Dose Changes with Hyperlipidemia Medications
  - goals met;
  - poor therapeutic response;
  - bothersome side-effects;
  - allergic response;
  - Other
- Other Reasons for Dose Changes with Hyperlipidemia Medications
- Reasons for Discontinuation with Hyperlipidemia Medications
  - goals met;
  - poor therapeutic response;
  - bothersome side-effects;
  - allergic response;
  - Other
- Other Reasons for Discontinuation with Hyperlipidemia Medications
- Does patient have history of anemia?
  - Yes
  - No
- Patient has
  - iron deficiency anemia ;
  - folate deficiency anemia
  - vitamin B12 deficiency anemia ;
  - Other
- Other Types of Anemia
- Supplementation for Anemia
  - Patient is on supplementation for the same.
  - Patient is not on any supplementation.
  - Patient was started on supplementation during the episode.
- Recent Changes with Supplementation for Anemia
  - Patient/caregiver reports no changes with regards to supplements for anemia and doses Patient was started on supplementation during the episode.
  - Patient was started on supplementation to manage symptoms of anemia Patient was started on supplementation during the episode.
  - Patient's dose with anemia supplementation was changed during the episode.
  - Patient was discontinued on anemia supplementation during the episode.
- Reasons for Dose Changes with Supplementation for Anemia
  - poor therapeutic response;
  - increased shortness of breath;
  - compromised endurance;
  - episodes of blood loss;
  - poor nutrition;
  - scheduled surgery;
  - episodes of gastric bleeding;
  - bleeding;
  - bleeding hemorrhoids;
  - melena;
  - bothersome side-effects;
  - allergic response;
  - Other
- Other Reasons for Dose Changes with Supplementation for Anemia
- Reasons for Discontinuation of Anemia Supplementation
  - poor therapeutic response;
  - increased shortness of breath;
  - compromised endurance;
  - episodes of blood loss;
  - poor nutrition;
  - scheduled surgery;
  - episodes of gastric bleeding;
  - bleeding;
  - bleeding hemorrhoids;
  - melena;
  - bothersome side-effects;
  - allergic response;
  - Other
- Other Reasons for Discontinuation of Anemia Supplementation
- Exacerbation of Anemia
  - Patient presents with poor endurance and SOB.
  - Patient presents with delayed capillary refill.
  - Patient presents with pale skin and mucous membranes.
- No exacerbation of Anemia
  - Patient/caregiver reports no gross exacerbation of SOB and compromised endurance during the episode.
  - Patient presents with capillary refill less than 3 seconds.
  - Skin and mucous membranes are pink in color and healthy.
- Does patient have a complaint of Peripheral Vascular Disease?
  - Yes
  - No
- Peripheral Vascular Disease
  - Patient has history of peripheral vascular disease.
  - Patient was diagnosed with peripheral vascular disease during the episode.
- Peripheral vascular disease involves
  - RUE ;
  - LUE ;
  - BUE ;
  - RLE ;
  - LLE ;
  - BLE ;
- Reasons for Poor Distal Blood Circulation
  - chronic smoking ;
  - chronic poorly controlled diabetes ;
  - Other
- Other Reasons for Poor Distal Blood Circulation
- Normal Findings
  - Peripheral pulses were palpable 2+ x 4 extremities.
  - Capillary refill was noted to be less than 3 seconds.
  - Toes appeared pink in color.
  - BLE were felt warm to touch.
- Abnormal Findings for PVD
  - Peripheral pulses were hardly palpable in distal extremities
  - Patient presents with delayed capillary refill.
  - Distal extremities were felt cold to touch.
  - BLE are discolored with some bluish coloration to the feet.
- Is the patient on any blood thinners or anticoagulants?
  - Yes
  - No
- Deep Vein Thrombosis
  - Patient has history of DVT.
  - Patient has history of pulmonary emboli.
  - Patient is more prone for clot formation.
  - Patient presented with an episode of DVT during the certification period.
  - Patient presented with an episode of pulmonary embolus during the certification period.
  - Patient had an episode of hospitalization during the certification period, secondary to clot formation.
- Reasons for Risk for Clot Formation
  - reduced ROM ;
  - increase in sedentary lifestyle ;
  - artificial heart valves ;
  - arrhythmia ;
  - medications side effects ;
  - Other
- Other Reasons for Risk for Clot Formation
- Patient is currently on
  - Lovenox ;
  - Coumadin ;
  - Baby aspirin ;
  - Plavix ;
  - Other
- Other anticoagulants that patient is taking
- Is patient independent with Lovenox administration?
  - Yes
  - No
- Is patient informative regarding Coumadin diet?
  - informative
  - poorly informative
  - moderately informative
- Compliance reported with Coumadin diet
  - compliance
  - partial compliance
  - noncompliance
- Findings watched for on assessment today
  - No bruises noted currently.
  - Mild ecchymoses and bruises, in various stages of healing, were noted on the extremities.
  - Patient/caregiver reports no episodes of acute exacerbation of SOB lately.
  - Patient/caregiver reports to have noted no episodes of hematuria or blood in stool.
  - Patient/caregiver report occasional episodes of red brown urine and dark colored stool, probably secondary to internal bleed due to the anticoagulant intake.
  - Physician was notified on the symptoms of bleeding.
  - Patient/caregiver reports an episode of acute exacerbation of SOB lately, probably due to formation of pulmonary embolus.
  - Patient reports acute pain and tenderness in the calf muscle of lower extremity, with swelling of limb beneath the calf, which is a sign of clot formation.
  - Physician was notified on the symptoms of clot formation.
- Lab Draws
  - Regular weekly labs for INR are being drawn.
  - Regular weekly labs for INR are ordered.
- Is patient informative regarding blood thinner and anticoagulant precautions?
  - informative
  - poorly informative
  - moderately informative
- INR Reading Today (number only)
- Last INR Reading (number only)
- PT Reading Today (number only)
- Last PT Reading (number only)
- Recent Changes with Blood Thinners/Anticoagulants
  - Patient has been on blood thinners/anticoagulants for long time to prevent clot formation.
  - Patient/caregiver reports no changes with regards to blood thinner/anticoagulant medications and doses during the episode.
  - Patient was started on blood thinners/anticoagulants to reduce risk for clot formation during the episode.
  - Patient’s dose of blood thinners/anticoagulants was changed during the episode.
  - Patient was discontinued on blood thinners/anticoagulant during the episode..
- Reasons for Dose Changes with Blood Thinners/Anticoagulants
  - poor anticoagulation response;
  - low INR reading;
  - increased risk for clot formation;
  - clot formation;
  - increased thinning of blood;
  - high INR reading;
  - increased risk for bleeding;
  - bleeding;
  - hematemesis;
  - melena;
  - bothersome side-effects;
  - allergic response;
  - Other
- Other Reasons for Dose Changes with Blood Thinners/Anticoagulants
- Reasons for Discontinuation with Blood Thinners/Anticoagulants
  - poor anticoagulation response;
  - low INR reading;
  - increased risk for clot formation;
  - clot formation;
  - increased thinning of blood;
  - high INR reading;
  - increased risk for bleeding;
  - bleeding;
  - hematemesis;
  - melena;
  - bothersome side-effects;
  - allergic response;
  - Other
- Other Reasons for Discontinnuation with Blood Thinners/Anticoagulants
- Does patient have history of valvular disease?
  - Yes
  - No
- Patient is a known case of
  - Mitral stenosis ;
  - Mitral regurgitation ;
  - Tricuspid stenosis ;
  - Tricuspid regurgitation ;
  - Pulmonic stenosis ;
  - Pulmonic regurgitation ;
  - Other
- Other Valvular Disease
- Correction Measures
  - No active measures suggested for valvular abnormality, as of now.
  - Patient has history of surgical correction for valvular abnormality.
  - Patient was recommended surgical correction of valvular abnormality during the episode.
  - Patient underwent surgical correction of valvular abnormality during the episode.
- Additional Information-Cardiovascular Status
- GU
- Select As Applicable
- Does the patient have complaint of BPH?
  - Yes
  - No
- Benign Prostatic Hypertrophy
  - Patient was recently diagnosed with BPH.
  - Patient has history of BPH.
- Issues Related to BPH
  - difficulty starting urination ;
  - weak urine stream ;
  - interrupted urine flow ;
  - urine retention ;
  - Other
- Other Issues Related to BPH
- No Active Symptoms of BPH
  - Patient/caregiver reports no active bothersome symptoms of BPH.
  - Patient/caregiver reports mild, on and off symptoms of BPH, with no gross exacerbation of symptoms during the episode.
  - Symptoms of BPH are reportedly controlled with no gross exacerbation in recent times.
- Active Symptoms and Exacerbation of BPH
  - Patient/caregiver reports moderate to severe complaint of urinary retention and difficulty starting urination.
  - Exacerbation of symptoms of BPH were reported during the episode.
- Medications for BPH
  - Patient/caregiver reports no changes with regards to medications/doses for management of symptoms of BPH during the episode.
  - Patient was started on medications, for improved control of symptoms of BPH during the episode.
  - Dose change with BPH medications reported in recent times.
  - Patient was recently discontinued on medications for management of BPH.
- Reasons for Dose Changes with BPH Medications
  - goals met;
  - improved control of BPH symptoms;
  - poor therapeutic response;
  - exacerbation of BPH symptoms;
  - bothersome side effects of medication;
  - allergic response;
  - Other
- Reasons for Dose Changes with BPH Medications
- Reasons for BPH Medications Discontinuation
  - goals met;
  - improved control of BPH symptoms;
  - poor therapeutic response;
  - exacerbation of BPH symptoms;
  - bothersome side effects of medication;
  - allergic response;
  - Other
- Other Reasons for BPH Medications Discontinuation
- Does patient have history of prostate cancer?
  - Yes
  - No
- Prostate Cancer
  - Patient has history of prostate cancer.
  - Patient was diagnosed with prostate cancer during the episode.
  - Relapse of prostate cancer reported during the episode.
  - Prostate cancer is currently active.
  - Prostate cancer is currently in remission.
  - No relapse of prostate cancer reported so far.
  - Patient is being followed-up periodically.
- Cancer was reported to be
  - benign
  - malignant
- Date of last prostate exam
- Prostate Cancer Symptoms
  - Patient reports straining to pass urine and urinary retention, secondary to the prostate cancer.
  - Patient reports no current complaints of urinary retention and straining to pass urine.
- Metastases of Prostate Cancer
  - No metastases were reportedly identified so far.
  - Skeletal metastases to prostate cancer reported.
- Specific sites of metastases (name only)
- Therapy Measures for Prostate Cancer
  - Patient has history of undergoing chemotherapy.
  - Patient has history of undergoing radiation therapy.
  - Patient is currently undergoing chemotherapy
  - Patient is currently undergoing radiation therapy.
  - Patient is currently being considered for chemotherapy..
  - Patient is currently being considered for radiation therapy.
  - Patient has history of prostatectomy.
  - Patient lately underwent prostatectomy.
  - Patient is currently being considered for a prostatectomy.
- TURP Procedure
  - Patient has remote history of TURP for symptoms of urinary retention.
  - Patient underwent TURP during the episode, for symptoms of urinary retention and BPH.
  - Patient is being scheduled for TURP for symptoms of urinary retention.
- Knowledge regarding double voiding
  - is informative
  - is poorly informative
  - needs instructions
- Compliance regarding double voiding
  - compliance
  - partial compliance
  - non compliance
- Most recent PSA levels
  - WNL
  - elevated
- Does patient have history of polyuria?
  - Yes
  - No
- Polyuria
  - Patient has history of polyuria.
  - Polyuria is a recent complaint on patient’s profile.
- Causes of Polyuria
  - new diuretic medication patient was started on lately.;
  - Poorly controlled blood sugars in recent times;
  - currently active episode of UTI;
  - urinary retention due to prostate enlargement ;
  - Other
- Other causes of polyuria
- Risk for UTI
  - Patient is a known case of increased risk for UTI.
  - Patient has history of multiple UTIs in recent times.
- Causes of Increased Risk for UTI Exacerbation
  - patient's BPH and consequent urinary retention;
  - patient's history of renal stones;
  - patient's self-catheterization;
  - patient's poor hydration status;
  - patient's poor hygienic practices;
  - Other
- Other Causes of Increased Risk for UTI Exacerbation
- UTI in Recent Time
  - Patient suffered a hospitalization during the episode, secondary to UTI.
  - Patient currently has no active episode of UTI.
  - Patient currently has an active episode of UTI.
  - Patient/caregiver reports UTIs in recent times.
- Number of UTI Episodes in Recent Time
- Symptoms of UTI
  - increased frequency of urination;
  - burning sensation while urinating;
  - foul smelling urine;
  - Other
- Other Symptoms of UTI
- Resolution of Symptoms of UTI
  - resolved;
  - reportedly stable;
  - moderately controlled;
  - worsened lately;
  - on and off;
  - Other
- Other Resolution for Symptoms of UTI
- Treatment and Management Measures for UTI
  - Patient is on a daily prophylactic antibiotic regimen for UTI prevention.
  - Patient takes a cranberry pill every day for UTI prophylaxis.
  - Patient/caregiver reports no changes with regards to medications/doses for management of UTI during the episode.
  - Patient was started on medication for UTI during the episode.
  - Patient's dose with UTI medication was recently changed.
  - Patient was discontinued on UTI medication lately.
- Reasons for Dose Changes with UTI Medication
  - goals met;
  - improved control of UTI symptoms;
  - poor therapeutic response;
  - exacerbation of UTI symptoms;
  - bothersome side effects of medication;
  - allergic response;
  - Other
- Other Reasons for Dose Changes with UTI Medication
- Reasons for Discontinuation with UTI Medication
  - goals met;
  - improved control of UTI symptoms;
  - poor therapeutic response;
  - exacerbation of UTI symptoms;
  - bothersome side effects of medication;
  - allergic response;
  - Other
- Other Reasons for Discontinuation with UTI Medication
- Does patient have history of urinary and bowel incontinence?
  - Yes
  - No
- Urinary Incontinence
  - Patient has decent bladder control and reports no urinary incontinence.
  - Lately, patient reports poor bladder control with increasing frequency of episodes of incontinence.
  - Patient reports history of poor bladder control with occasional accidents happening.
- Stress Incontinence
  - Patient has history of stress incontinence.
  - Exacerbation of stress incontinence reported over the episode.
  - On and off episodes of stress incontinence reported, with no exacerbation lately.
- Urge Incontinence
  - Patient has history of bladder spasms and consequent urge incontinence.
  - Patient reports poor bladder control with increasing frequency of episodes of incontinence during the certification period.
  - On and off episodes of urge incontinence reported, with no exacerbation during the episode.
- Control of urinary incontinence
  - well controlled
  - moderately controlled
  - poorly controlled
- Bowel Incontinence
  - Patient has decent bowel control and reports no bowel incontinence.
  - Patient reports poor bowel control with increasing frequency of episodes of incontinence during the episode.
  - Patient has history of poor bowel control, with occasional accidents happening.
- Control of bowel incontinence
  - well controlled
  - moderately controlled
  - poorly controlled
- Causes for Incontinence
  - history of low back injury and consequent poor bowel and bladder control.
  - history of weak pelvic floor from multiple child births, which contribute significantly to her incontinence.
  - on and off episodes of bladder spasms contribute to urinary incontinence.
  - history of neurogenic bladder contributing to urinary incontinence.
  - Other
- Other Causes for Incontinence
- Management Measures for Incontinence
  - Patient regularly wears depends.
  - Timed voiding defers incontinence.
  - SN to train the patient on timed voiding to help manage urinary incontinence.
  - Patient was trained on timed voiding to help manage episodes of urinary incontinence.
  - Patient is on Oxybutynin for control of bladder spasms.
  - Kegel exercises help reduce frequency of incontinence episodes and accidents.
  - Patient was recommended ostomy.
  - Patient is on ostomy currently.
- Is patient knowledgeable regarding Kegel exercises?
  - Yes
  - No
- Compliance with Kegel exercises
  - compliance
  - partial compliance
  - noncompliance
- Is patient knowledgeable regarding timed voiding instructions?
  - Yes
  - No
- Compliance with Timed Voiding Instructions
  - compliance
  - partial compliance
  - noncompliance
- Does patient have history of bladder cancer?
  - Yes
  - No
- Bladder Cancer
  - Patient has history of bladder cancer.
  - Patient was diagnosed with bladder cancer during the episode.
  - Cancer was reported to be benign.
  - Cancer was reported to be malignant.
  - Relapse of bladder cancer reported lately.
  - Bladder cancer is currently active.
  - Bladder cancer is currently in remission.
  - No relapse of bladder cancer reported so far.
  - Patient is being followed-up periodically.
- Were any metastases identified?
  - Yes
  - No
- Sites of Metastases (name only)
- Bladder Excision
  - Patient has history of bladder excision.
  - Patient underwent bladder excision during the episode.
  - Patient is currently being considered for a bladder excision.
- History of Therapy for Bladder Cancer
  - radiation therapy;
  - chemotherapy;
  - Other
- History of Other Therapy Measures for Bladder Cancer
- Current Therapy Measures for Bladder Cancer
  - radiation therapy;
  - chemotherapy;
  - Other
- Current Other Therapy Measures for Bladder Cancer
- Does the patient have any history of urostomy?
  - Yes
  - No
- Urostomy
  - Patient is chronically urostomy dependent.
  - Patient was started on urostomy during the episode.
  - Patient is currently being considered for urostomy.
- Reasons for Urostomy
  - bladder cancer;
  - spinal cord injury;
  - birth defect;
  - poor bladder control;
  - bladder excision;
  - neurogenic bladder;
  - Other
- Other Reasons for Urostomy
- Urostomy Site Appearance
  - pink, with no erythema around.
  - mildly inflamed and erythematous.
  - moderately inflamed and erythematous.
- Is patient independent with urostomy care and bag change?
  - Yes
  - No
- Bag Change Today
  - Bag was in place and in good standing.
  - Bag was due for change.
  - No bag change was performed today.
  - Bag was changed during the visit today.
- Date on which bag was changed last
- Is patient currently on urinary catheter?
  - Yes
  - No
- Foley Catheter
  - Patient has been on Foley catheter for some time.
  - SN to perform Foley catheter change, once every week and as needed.
  - Patient was started on Foley catheter during the episode.
- Suprapubic Catheter
  - Patient has been on suprapubic catheter for some time.
  - SN to perform suprapubic catheter change, once every month and as needed.
  - Patient was started on suprapubic catheter during the episode.
- Patient’s urinary catheter status is secondary to
  - post-surgical phase;
  - stone formation;
  - neurogenic bladder;
  - spinal cord injury;
  - poor bladder control;
  - urinary tract obstruction due to stone formation;
  - urinary tract obstruction due to tumor;
  - Other
- Other Reasons for Patient's Urinary Catheter Status
- Independence with Catheter Irrigation and Care
  - Patient is independent with catheter irrigation and care.
  - Patient is dependent upon caregiver assistance for catheter irrigation and care.
  - No dependable caregiver is available for catheter irrigation and care. Home health to offer assistance, as needed.
  - Patient/caregiver needs training on catheter irrigation and care.
  - SN to train the patient/caregiver upon catheter flushing and care as ordered.
- Independence with Catheter Change
  - Patient is independent with catheter change.
  - Patient is dependent upon caregiver assistance for catheter change.
  - No dependable caregiver is available for catheter change. Home health to offer assistance, as ordered.
  - Patient/caregiver needs training on catheter change.
  - SN to train the patient/caregiver upon catheter change, as ordered.
- Intermittent Catheterization
  - Patient has been using intermittent catherization for bladder emptying for quite some time.
  - Patient was started on intermittent catheterization during the episode, as retention of urine has been a problem.
- Patient’s intermittent catheterization is secondary to
  - incomplete bladder emptying;
  - urinary retention;
  - exacerbation of BPH;
  - neurogenic bladder;
  - spinal cord injury;
  - poor bladder control;
  - urinary tract obstruction due to stone formation;
  - urinary tract obstruction due to tumor;
  - Other
- Other Reasons for Patient’s Intermittent Catheterization
- Independence with Intermittent Catheterization
  - Patient is independent with performing intermittent catheterization and care.
  - Patient is dependent upon caregiver assistance for intermittent catheterization and care.
  - Patient/caregiver needs training on performing intermittent catheterization and care.
  - SN to train the patient/caregiver upon intermittent catheterization and care during the episode.
- Catheter Care Today
  - Catheter was in place and in good standing.
  - No catheter change was performed today.
  - Catheter was due for change.
  - SN irrigated the catheter during the visit.
  - SN instructed the patient/caregiver upon catheter flushing and change during the visit.
  - No resistance noted during catheter irrigation today.
  - Mild resistance noted during catheter irrigation today.
  - Catheter was noted to be blocked during irrigation.
  - Catheter was changed during the visit today.
  - SN instructed the patient/caregiver upon intermittent catheterization and care during the visit.
  - SN performed intermittent catheterization and care during the visit today.
- Date on which catheter was changed last
- Any abnormalities noted with urine in the bag?
  - Yes
  - No
- Abnormalities Noted with Urine in the bag
  - low 24-hour volume;
  - blood-tinged urine;
  - increased sediment to urine;
  - Other
- Other abnormalities noted with urine in the bag
- Does patient have history of renal failure/CKD?
  - Yes
  - No
- Renal Function
  - No compromise with renal function reported.
  - Patient renal function was recently diagnosed to be in an early stage of compromise.
  - Patient has history of compromised renal function.
- Causes for Diminished Renal Function
  - poorly controlled diabetes ;
  - poorly controlled chronic hypertension ;
  - NSAID abuse ;
  - chronic history of renal stones and recurrent pyelonephritis ;
  - Other
- Other causes for diminished renal function
- Current Stage of Renal Failure (number only)
- Deterioration of Renal Function
  - Deterioration of renal function has been stable, with no progression in recent times.
  - Patient is in end-stage renal disease.
  - Patient will be soon started on dialysis.
  - No update is available on the current renal function status.
  - Patient’s renal function has progressively deteriorated over the episode.
- Signs and Symptoms of Renal Failure
  - reduced urine volume;
  - anuria;
  - fluid retention and edema;
  - fatigue and weakness;
  - confusion;
  - episodes of disorientation;
  - shortness of breath;
  - poorly controlled blood pressure;
  - Other
- Other Signs and symptoms of Renal Failure
- Renal Transplant
  - Patient was recommended for renal transplant.
  - Patient is being scheduled for a renal transplant.
  - Patient has history of undergoing renal transplantation.
  - Patient underwent renal transplantation during the episode.
  - Patient is on immunosuppression to prevent transplant rejection.
  - Patient’s renal function is being closely monitored.
- Is patient dependent on dialysis?
  - Yes
  - No
- Dialysis
  - Patient was started on dialysis recently.
  - Patient has been on dialysis for long time.
  - Patient attends the dialysis clinic three times a week.
  - Patient was recommended dialysis three times a week and will start receiving it soon.
- Dialysis Access Site
  - Patient has the access site on the left arm. No blood pressure readings to be taken on the left arm.
  - Patient has the access site on the right arm. No blood pressure readings to be taken on the right arm.
- Additional Information-GU
- GI
- Select As Applicable
- Does patient have any complaint of nausea/vomiting?
  - Yes
  - No
- Reasons for Nausea and Vomiting
  - side-effects of medications;
  - chemotherapy;
  - radiation therapy;
  - motion sickness;
  - gastritis;
  - Other
- Other Reasons for Nausea and Vomiting
- Relief Measures for Nausea and Vomiting
  - Patient is currently on medication for relief of nausea and vomiting.
  - Patient/caregiver reports no changes with regards to medications/doses for managing nausea and vomiting during the episode.
  - Patient was started on medication for better control of nausea and vomiting during the episode.
  - Patient’s dose on medication for nausea and vomiting was changed during the episode.
  - Patient was recently discontinued on medication for nausea and vomiting.
- Reasons for Dose Change for Nausea and Vomiting
  - poor therapeutic response;
  - episodes of worsening dizziness;
  - bothersome side-effects;
  - allergic response;
  - Other
- Other Reasons for Dose Change for Nausea and Vomiting
- Reasons for Medication Discontinuation for Nausea and Vomiting
  - poor therapeutic response;
  - episodes of worsening dizziness;
  - bothersome side-effects;
  - allergic response;
  - Other
- Other Reasons for Medication Discontinuation for Nausea and Vomiting
- Response to Relief Measures for Nause and Vomiting
  - decently controlled
  - moderately controlled
  - poorly controlled
- Bowel sounds
  - were actively heard
  - hypoactive
  - hyperactive
- Does patient have any complaint of constipation?
  - Yes
  - No
- Constipation
  - Bowel movements have more or less been regular during the episode, with no exacerbation of constipation.
  - Constipation has been a chronic complaint.
  - No bowel movement reported in the last 3 days.
  - Patient presented with on and off episodes of slowed bowel movements during the episode.
  - No episodes of acute constipation reported during the certification period.
- Exacerbation of Constipation
  - Patient presented with no acute exacerbation of constipation lately.
  - Patient presented with episodes of acute exacerbation of constipation during the certification period.
  - Acute exacerbation of constipation over the episode contributed to impaction and administration of enema.
  - Patient also had an ER visit during the episode, secondary to the fecal impaction.
- Causes of Constipation
  - pain killers use ;
  - intake of iron supplements ;
  - sedentary life style ;
  - poor fluid intake ;
  - low fiber intake ;
  - Other
- Other causes of constipation
- Does patient take any laxatives for constipation relief?
  - Yes
  - No
- Laxatives and Stool Softeners
  - milk of magnesia ;
  - mineral oil ;
  - senna ;
  - docusate ;
  - miralax ;
  - psyllium ;
  - metamucil ;
  - Other
- Other laxatives/stool softener
- Recent Changes with Laxatives and Stool Softeners
  - Patient/caregiver reports no changes with regards to laxative and stool softener medications/doses for managing constipation during the episode.
  - Patient/caregiver reports taking laxatives and stool softeners, only as needed.
  - Patient was started on laxatives and stool softeners for better relief of constipation during the episode.
  - Patient’s dose on laxatives and stool softeners was changed recently.
  - Patient was recently discontinued on laxatives and stool softeners.
- Reasons for Dose Changes with Laxatives and Stool Softeners
  - goals met;
  - increased activity;
  - poor therapeutic response;
  - reduced sedentary lifestyle;
  - reduced need for intake of pain medication;
  - exacerbation of constipation episodes;
  - episodes of worsening dizziness;
  - bothersome side-effects;
  - allergic response;
  - Other
- Other Reasons for Dose Changes with Laxatives and Stool Softeners
- Reasons for Discontinuation with Laxatives and Stool Softeners
  - goals met;
  - increased activity;
  - poor therapeutic response;
  - reduced sedentary lifestyle;
  - reduced need for intake of pain medication;
  - exacerbation of constipation episodes;
  - episodes of worsening dizziness;
  - bothersome side-effects;
  - allergic response;
  - Other
- Other Reasons for Discontinuation with Laxatives and Stool Softeners
- Response to laxatives/stool softener
  - relief
  - moderate relief
  - poor relief
- Does patient have any complaint of diarrhea?
  - Yes
  - No
- Diarrhea
  - Patient/caregiver reports an episode of acute diarrhea for the last one week.
  - Patient reports presenting with one episode of diarrhea lately.
  - Patient/caregiver reports chronic history of on and off diarrhea episodes.
  - Diarrhea is self-contained and resolved during the episode.
- Reasons for Acute Diarrhea
  - viral infection;
  - bacterial infection;
  - antibiotic intake;
  - lactose intolerance;
  - Other
- Other Reasons for Acute Diarrhea
- Reasons for Chronic Diarrhea
  - crohn’s disease;
  - ulcerative colitis;
  - celiac disease;
  - irritable bowel syndrome;
  - Other
- Other Reasons for Chronic Diarrhea
- Management Measures for Diarrhea
  - Diarrhea is self-limited and no active measures were suggested.
  - Patient is currently on medication for management of diarrhea.
  - Patient/caregiver reports no changes with regards to antidiarrheal medications/doses Diarrhea is self-contained and resolved during the episode.
  - Patient was started on medication for improved control of diarrhea Diarrhea is self-contained and resolved during the episode.
  - Patient’s dose on antidiarrheal medication was changed Diarrhea is self-contained and resolved during the episode.
  - Patient was recently discontinued on antidiarrheal medication.
- Reasons for Changes with Antidiarrheal Medications
  - goals met;
  - improved control of diarrhea;
  - poor therapeutic response;
  - exacerbation of diarrhea episodes;
  - episodes of worsening dizziness;
  - bothersome side-effects;
  - allergic response;
  - Other
- Other Reasons for Changes with Antidiarrheal Medications
- Reasons for Discontinuation of Antidiarrheal Medications
  - goals met;
  - improved control of diarrhea;
  - poor therapeutic response;
  - exacerbation of diarrhea episodes;
  - episodes of worsening dizziness;
  - bothersome side-effects;
  - allergic response;
  - Other
- Other Reasons for Discontinuation of Antidiarrheal Medications
- Does patient have history of hemorrhoids?
  - Yes
  - No
- Hemorrhoids
  - Patient has history of internal hemorrhoids.
  - Patient has history of external hemorrhoids.
  - Patient presented with recent onset of hemorrhoids during the episode.
- Bleeding per Rectum
  - No episodes of bleeding per rectum reported in recent times.
  - On and off episodes of bleeding per rectum reported during the episode.
  - Exacerbation of episodes of bleeding per rectum reported during the certification period.
  - Patient has been on iron supplementation to cover for the deficiency, secondary to blood loss.
  - Blood loss resulted in anemia and patient was started on iron supplementation lately.
  - No active measures are reportedly being considered currently for the hemorrhoids.
  - Patient has history of hemorrhoidectomy.
- Does patient have history of peptic ulcer disease?
  - Yes
  - No
- Peptic Ulcer Disease
  - Patient has long standing history of peptic ulcer disease.
  - Patient was recently diagnosed with peptic ulcer disease.
  - Patient currently has active H. pylori infection and is on antibiotics for the same.
- Exacerbation of Peptic Ulcer Symptoms
  - No activation of peptic ulcer symptoms reported during the episode.
  - Patient reports on and off activation of symptoms of peptic ulcer during the episode.
  - Exacerbation of symptoms of peptic ulcer disease reported during the episode.
  - Patient/caregiver reports continuing episodes of heartburn.
  - Bloating and stomach pain reported.
- Relief Measures for Peptic Ulcer Disease and Compliance
  - Patient was recommended lifestyle modifications for management of peptic ulcer symptoms.
  - Patient has been compliant over the episode, with recommendations made for management of peptic ulcer disease
  - Patient has been moderately compliant over the episode, with recommendations made for management of peptic ulcer disease.
  - Patient is poorly compliant with recommendations made for management of peptic ulcer disease, as caregiver reports.
- Risk Factors Peptic Ulcer Disease
  - Recurrent H. pylori infections ;
  - History of NSAID abuse ;
  - Chronic smoking history ;
  - Chronic alcoholism ;
  - intake of spicy food ;
  - excessive caffeine intake ;
  - Other
- Other risk factors for peptic ulcer disease
- Medications for Management of Peptic Ulcer Disease
  - Omeprazole ;
  - Pantoprazole ;
  - Ranitidine ;
  - Lansoprazole ;
  - Cimetidine ;
  - Other
- Other medications for peptic ulcer disease management
- Changes with Peptic Ulcer Disease Medications
  - Patient/caregiver reports no changes with regards to medications/doses for management of symptoms of peptic ulcer disease during the episode.
  - Patient was started on new medications for improved control of symptoms of peptic ulcer disease.
  - Patient's dose on medications for peptic ulcer disease was changed recently.
  - Patient was recently discontinued on medications for peptic ulcer disease.
- Reasons for Dose Changes with Peptic Ulcer Disease Medications
  - goals met;
  - improved control of peptic ulcer symptoms;
  - poor therapeutic response;
  - exacerbation of heart burn episodes;
  - worsening bloating;
  - recurrent episodes of stomach pain;
  - bothersome side-effects;
  - allergic response;
  - Other
- Other Reasons for Dose Changes with Peptic Ulcer Disease Medications
- Reasons for Discontinuation of Peptic Ulcer Disease Medications
  - goals met;
  - improved control of peptic ulcer symptoms;
  - poor therapeutic response;
  - exacerbation of heart burn episodes;
  - worsening bloating;
  - recurrent episodes of stomach pain;
  - bothersome side-effects;
  - allergic response;
  - Other
- Other Reasons for Discontinuation of Peptic Ulcer Disease Medications
- Does patient have history of GERD?
  - Yes
  - No
- GERD
  - Patient has long standing history of GERD.
  - Patient was recently diagnosed with GERD.
- Contributory Factors for GERD
  - obesity ;
  - continued smoking status ;
  - with irregular eating habits ;
  - history of partial gastrectomy due to which patient is prone for reflux symptoms, due to small stomach size ;
  - Other
- Additional contributory GERD factors
- Exacerbation of GERD
  - No recent activation of GERD reported.
  - Patient reports on and off activation of symptoms of GERD during the episode.
  - Exacerbation of symptoms of GERD reported during the episode.
  - Patient/caregiver reports continuing episodes of heartburn.
  - Episodes of bloating and burning sensation in the throat reported.
- Relief Measures for GERD and Compliance
  - Patient was recommended lifestyle modifications for management of GERD symptoms.
  - Patient has been compliant over the episode, with recommendations made for management of GERD.
  - Patient has been moderately compliant over the episode, with recommendations made for management of GERD.
  - Patient is poorly compliant with recommendations made for management of GERD, as caregiver reports.
- Risk Factors GERD
  - fatty food ;
  - Chronic smoking history ;
  - Chronic alcoholism ;
  - intake of spicy food ;
  - excessive caffeine intake ;
  - Other
- Other Risk Factors for GERD
- Medications for Management of GERD
  - Omeprazole ;
  - Pantoprazole ;
  - Ranitidine ;
  - Lansoprazole ;
  - Cimetidine ;
  - Other
- Other medications for GERD
- Recent Changes with GERD Medications
  - Patient/caregiver reports no changes with regards to medications/doses for management of symptoms of GERD during the episode.
  - Patient was started on new medications for management of GERD during the episode.
  - Patient's dose with GERD medications was changed recently.
  - Patient was recently discontinued on GERD medications.
- Reasons for Dose Changes with GERD Medications
  - goals met;
  - improved control of GERD symptoms;
  - poor therapeutic response;
  - exacerbation of heart burn episodes;
  - worsening bloating;
  - recurrent episodes of burning sensation in the throat;
  - bothersome side-effects;
  - allergic response;
  - Other
- Other Reasons for Dose Changes with GERD Medications
- Reasons for Discontinuation of GERD Medications
  - goals met;
  - improved control of GERD symptoms;
  - poor therapeutic response;
  - exacerbation of heart burn episodes;
  - worsening bloating;
  - recurrent episodes of burning sensation in the throat;
  - bothersome side-effects;
  - allergic response;
  - Other
- Other Reasons for Discontinuation of GERD Medications
- Does patient have history of colon cancer?
  - Yes
  - No
- Colon Cancer
  - Patient has history of colon cancer.
  - Patient was recently diagnosed with colon cancer.
  - Cancer was reported to be benign.
  - Cancer was reported to be malignant.
  - Relapse of colon cancer reported lately.
  - Colon cancer is currently active.
  - Colon cancer is currently in remission.
  - No relapse of colon cancer reported so far.
  - Patient is being followed-up periodically.
- Date on which patient had last colonoscopy
- Colectomy for Colon Cancer
  - Patient has history of colectomy.
  - Patient lately underwent colectomy.
  - Patient is currently being considered for a colectomy.
- History of Therapy Measures for Colon Cancer
  - radiation therapy;
  - chemotherapy;
  - Other
- History of Other Therapy Measures for Colon Cancer
- Current Therapy Measures for Colon Cancer
  - radiation therapy;
  - chemotherapy;
  - Other
- Current Other Therapy Measures for Colon Cancer
- Were any Metastases identified?
  - Yes
  - No
- Sites of Metastases (name only)
- Does patient have history of diverticulosis?
  - Yes
  - No
- Diverticulosis
  - Patient has history of diverticulosis.
  - Patient was diagnosed with diverticulosis during the episode.
- Organs involved in diverticulosis
  - colon;
  - small intestine;
  - large intestine;
  - Other
- Other organs involved in diverticulosis
- Current state of diverticulosis
  - Patient has history of resection of involved bowel segment.
  - Patient/caregiver reports on and off continuing episodes of abdominal pain and diarrhea.
  - No recent exacerbation of symptoms of diverticulitis reported during the episode.
  - Exacerbation of symptoms of diverticulitis reported during the episode.
  - Patient is recommended life-style modifications, such as, fiber diet and meeting fluid requirements for management.
  - No surgical measures suggested.
  - Patient lately underwent resection of involved bowel segment.
  - Patient is currently being considered for resection of involved bowel segment.
- Does patient have a history of colectomy?
  - Yes
  - No
- Patient's history of colectomy
  - recent partial coloctomy.
  - remote partial coloctomy.
  - recent total coloctomy.
  - remote total coloctomy.
- Reasons for Colectomy
  - colon cancer;
  - diverticulitis;
  - ulcerative colitis;
  - crohn's disease;
  - Other
- Other Reasons for Colectomy
- Does the patient have any history of ileostomy?
  - Yes
  - No
- Ileostomy
  - Patient is chronically ileostomy dependent.
  - Patient was started on ileostomy during the episode.
  - Patient has history of being on ileostomy and undergoing reversal.
  - Patient underwent reversal of ileostomy during the episode.
  - Patient is currently being considered for an ileostomy reversal.
  - Patient is currently being considered for ileostomy.
- Reasons for Ileostomy
  - crohn’s disease;
  - spinal cord injury;
  - ulcerative colitis;
  - colon cancer;
  - Other
- Other Reasons for Ileostomy
- Does the patient have any history of colostomy?
  - Yes
  - No
- Colostomy
  - Patient is chronically colostomy dependent.
  - Patient was started on colostomy during the episode.
  - Patient has history of being on colostomy and undergoing reversal.
  - Patient underwent reversal of colostomy during the episode.
  - Patient is currently being considered for a colostomy reversal.
  - Patient is currently being considered for colostomy.
- Reasons for Colostomy
  - crohn’s disease;
  - spinal cord injury;
  - ulcerative colitis;
  - colon cancer;
  - Other
- Other Reasons for Colostomy
- Ostomy Site Apppearence
  - pink, with no erythema around;
  - mildly inflamed and erythematous;
  - moderately inflamed and erythematous;
  - Other
- Other Signs at Ostomy Site
- Is patient independent with ostomy care and bag change?
  - Yes
  - No
- Bag Change Today
  - Bag was in place and in good standing.
  - Bag was due for change.
  - No bag change was performed today.
  - Bag was changed during the visit today.
- Date on which ostomy bag was last changed
- Additional Information-GI
- Nutrition
- Select As Applicable
- Appetite Changes
  - Appetite was fair and stable, over the episode, with no changes.
  - Appetite continues to be stably diminished.
  - Diminished appetite reported over the episode, with progressively diminishing intake of nutrition.
  - Appetite reportedly has started to improve lately, with steadily increasing intake.
- Causes of Diminished Appetite
  - nausea and vomiting due to chemo;
  - hypothyroidism;
  - dyspepsia and bloating;
  - gastrectomy;
  - depression;
  - Other
- Other Causes of Diminished Appetite
- Management Measures for Diminished Appetite
  - Patient/caregiver reports no changes with regards to medications/doses to help improve nutrition intake during the episode.
  - Patient is currently on medication to help promote diminishing appetite.
  - Patient was started on medication to help improve diminishing appetite during the episode.
  - Patient's dose of medication to improve appetite was recently changed.
  - Patient was recently discontinued on medication to help promote diminishing appetite.
- Reasons for Dose Changes with Medications to Improve Appetite
  - goals met;
  - poor therapeutic response;
  - bothersome side-effects;
  - allergic response;
  - Other
- Other Reasons for Dose Changes with Medications to Improve Appetite
- Reasons for Discontinuation of Medications to Improve Appetite
  - goals met;
  - poor therapeutic response;
  - bothersome side-effects;
  - allergic response;
  - Other
- Other Reasons for Discontinuation of Medications to Improve Appetite
- Meal Arrangement
  - Patient is independent with fixing meal.
  - Caregiver assists with fixing meal.
  - Patient is completely dependent on caregiver assistance for fixing meal.
  - Facility staff fixes the meal for the patient.
  - Patient mostly depends on frozen meal.
  - Patient receives assistance from meals on wheels, with one meal delivered every day.
- Dentures
  - Patient has a partial denture.
  - Patient has a complete denture.
  - Patient has a lot of missing teeth on both jaws and needs dentures.
  - Patient needs financial assistance with obtaining dentures.
  - Patient’s ability to chew solid foods is compromised.
- Weight changes in recent times
  - stable weight
  - progressive weight loss
  - progressive weight gain
  - abrupt weight loss
  - abrupt weight gain
- Does patient report any difficulties in chewing and swallowing?
  - Yes
  - No
- Chewing and Swallowing
  - Patient’s difficulty with chewing and swallowing is independent of consistency of food.
  - Patient has difficulty chewing and swallowing solid foods.
  - Patient has difficulty swallowing thin liquids.
- Reasons for Difficulty with Chewing and Swallowing
  - history of stroke;
  - hemiplegia involving face and neck muscles;
  - absence of teeth;
  - lack of dentures;
  - Other
- Other Reasons for Difficulty with Chewing and Swallowing
- Dysphagia Recommendations
  - thickener;
  - pureed diet;
  - mechanical soft diet;
  - Other
- Other Dysphagia Recommendations
- Aspiration in Recent Times
  - Difficulty with chewing and swallowing continues without any episodes of exacerbation lately.
  - No episodes of aspiration reported in recent times.
  - Exacerbation of dysphagia with on and off episodes of aspiration reported lately.
  - Increase in frequency of aspiration episodes reported in recent times.
  - Dysphagia and aspiration frequency with solids has reportedly improved in recent times.
  - Dysphagia and aspiration frequency with liquids has reportedly improved in recent times.
  - Patient is yet to gain control with regards to safe chewing and swallowing.
- ST Referral
  - ST referral made.
  - ST visits continuing.
  - ST discharged the patient, with HEP established.
- Does patient have any alternative feeding mechanisms?
  - Yes
  - No
- Alternative Feeding Mechanisms
  - NG tube
  - G-Tube
  - J-Tube
  - parenteral nutrition
- NG Tube
  - Patient is currently NPO.
  - Patient was started on NG-tube feedings during the episode.
  - Patient has been dependent on NG-tube feedings for quite some time.
- Indications for NG Tube Feeding
  - neck injury;
  - neck surgery;
  - difficulty chewing and swallowing;
  - poor intake of oral nutrition;
  - Other
- Other indications for NG-Tube Feeding
- Change of NG Tube
  - NG tube was not due for change.
  - NG tube was not changed today during the visit.
  - NG tube was changed today during the visit.
- Date on which NG tube was last changed
- Independence with NG-Tube Feedings and Management
  - Patient is independent with administration of tube feedings, management, checking tube placement and residual, flushing, and dressing changes, as needed.
  - Patient is dependent on caregiver assistance for NG tube feedings, management, checking tube placement and residual, flushing, and dressing changes, as needed.
  - SN to perform NG tube feedings, management, checking tube placement and residual, flushing, and dressing changes, as needed.
  - Patient/caregiver to be instructed on NG tube feedings, management, checking tube placement and residual, flushing, and dressing changes, as needed.
- Checking NG-Tube Placement
  - NG Tube placement was checked and was noted to be in place.
  - Tube was noted to be malpositioned, upon auscultation for borborygmi.
  - NG tube was replaced by SN today.
- Appearance of Site of NG-Tube Insertion
  - no signs and symptoms of infection;
  - no erythema;
  - erythema;
  - ulceration;
  - mild inflammation;
  - moderate inflammation
  - severe inflammation;
  - bleeding;
  - serous drainage;
  - mucus drainage;
  - purulent drainage;
  - Other
- Other signs at the site of NG tube insertion
- G-Tube Feedings
  - Patient is currently NPO.
  - Patient was started on G-tube feedings during the episode.
  - Patient has been dependent on G-tube feedings for quite some time.
- Indications for G-Tube Feeding
  - esophageal obstruction;
  - neck injury;
  - neck surgery;
  - difficulty chewing and swallowing;
  - poor intake of oral nutrition;
  - Other
- Other Indications for G-Tube Feeding
- Change of G-Tube
  - G tube was not due for change.
  - G tube was not changed today during the visit.
  - G tube was changed today during the visit.
- Date on which G-tube was last changed
- Independence with G-Tube Feedings and Dressing Changes
  - Patient is independent with administration of tube feedings, management, checking tube placement and residual, flushing, and dressing changes, as needed.
  - Patient is dependent on caregiver assistance for G tube feedings, management, checking tube placement and residual, flushing, and dressing changes, as needed.
  - SN to perform G tube feedings, management, checking tube placement and residual, flushing, and dressing changes, as needed.
  - Patient/caregiver to be instructed on G tube feedings, management, checking tube placement and residual, flushing, and dressing changes, as needed.
- Checking G-tube Placement
  - Tube placement was checked and was noted to be in place.
  - G tube was noted to be malpositioned, upon auscultation for borborygmi.
  - Physician was notified of the same.
  - G tube was replaced by SN today.
  - Patient is seeing the physician to have it fixed.
- G-Tube Dressing Change Today
  - SN performed the G-tube dressing change today.
  - SN to perform dressing changes at the feeding tube insertion site, as needed.
  - Patient/caregiver is independent at performing G-tube dressing change and takes care of it.
- Appearance of Site of G-Tube Insertion
  - no signs and symptoms of infection;
  - no erythema;
  - erythema;
  - ulceration;
  - mild inflammation;
  - moderate inflammation
  - severe inflammation;
  - bleeding;
  - serous drainage;
  - mucus drainage;
  - purulent drainage;
  - Other
- Other Signs at the Site of G-Tube Insertion
- J-Tube Feedings
  - Patient is currently NPO.
  - Patient was started on J-tube feedings during the episode.
  - Patient has been dependent on J-tube feedings for quite some time.
- Indications for J-Tube Feeding
  - esophageal obstruction;
  - neck injury;
  - neck surgery;
  - difficulty chewing and swallowing;
  - poor intake of oral nutrition;
  - Other
- Other Indications for J-Tube Feeding
- Change of J-Tube
  - J tube was not due for change.
  - J tube was not changed today during the visit.
  - J tube was changed today during the visit.
- Date on which J-tube was last changed
- Independence with J-Tube Feedings and Management
  - Patient is independent with administration of tube feedings, management, checking tube placement, flushing, and dressing changes, as needed.
  - Patient is dependent on caregiver assistance for J-tube feedings, management, checking tube placement, flushing, and dressing changes, as needed.
  - SN to perform J-tube feedings, management, checking tube placement, flushing, and dressing changes, as needed.
  - Patient/caregiver to be instructed on J-tube feedings, management, checking tube placement, flushing, and dressing changes, as needed.
- Checking J-Tube Placement
  - Tube placement was checked and was noted to be in place.
  - Tube was noted to be malpositioned, upon auscultation for borborygmi.
  - Physician was notified of the same.
  - J-tube was replaced by SN today.
  - Patient is seeing the physician to have it fixed. -tube was replaced by SN today.
- J-Tube Dressing Change Today
  - SN performed the J-tube dressing change today.
  - SN to perform dressing changes at the feeding tube insertion site, as needed.
  - Patient/caregiver is independent at performing J-tube dressing change and takes care of it.
- Appearance of Site of J-Tube Insertion
  - no signs and symptoms of infection;
  - no erythema;
  - erythema;
  - ulceration;
  - mild inflammation;
  - moderate inflammation
  - severe inflammation;
  - bleeding;
  - serous drainage;
  - mucus drainage;
  - purulent drainage;
  - Other
- Other Signs at the Site of J-Tube Insertion
- Administration of Parenteral Nutrition
  - PICC line
  - central line
- Feeding Details
  - bolus feeding;
  - continuous feeding;
  - Other
- Other Feeding Details
- Flush Protocol
  - The feeding line to be flushed before each feeding.
  - The feeding line to be flushed after each feeding.
- Does the patient have history of gastrectomy?
  - Yes
  - No
- History of Gastrectomy
  - partial gastrectomy
  - total gastrectomy
- Gastrectomy
  - Patient cannot accommodate much volume in the stomach, secondary partial gastrectomy.
  - Patient reportedly eats multiple small meals in a day, as accommodating a large meal is difficult.
- Reason for Gastrectomy
  - gastric cancer;
  - nonhealing gastric ulcer;
  - Other
- Other Reasons for Gastrectomy
- Is patient on any specific dietary recommendations?
  - Yes
  - No
- Dietary Recommendations
  - low salt diet ;
  - heart healthy diet ;
  - low fat diet ;
  - GERD diet ;
  - low calorie diet ;
  - ADA diet ;
  - coumadin diet ;
  - renal diet ;
  - gout diet;
  - high fiber diet ;
  - low fiber diet ;
  - high protein diet ;
  - gluten free diet ;
  - clear liquid diet ;
  - Mechanical soft diet ;
  - Pureed diet ;
  - Other
- Additional Dietary Recommendations
- Compliance with Dietary Recommendations
  - compliance
  - partial compliance
  - noncompliance
- Knowledge regarding Dietary Recommendations
  - Patient/caregiver is knowledgeable regarding the dietary recommendations made.
  - Patient/caregiver is poorly knowledgeable regarding the dietary recommendations made.
  - Patient/caregiver needs instructions regarding the dietary recommendations made. SN to provide the same during the episode.
- Additional Information-Nutrition
- Neuro/Emotional/Behavioral Status
- Select As Applicable
- Alertness
  - Patient was awake and alert through the appointment time.
  - Patient was awake, but hardly responsive through the appointment time.
  - Patient appeared very confused during the appointment time.
  - Episodes of confusion noted on and off during the episode.
  - Episodes of confusion have been stable in the last 2 months.
  - Episodes of confusion presented with increased frequency over the episode.
  - Episodes of confusion are characteristically reported only during the night.
  - Episodes of confusion are irrespective to the time of day.
- Orientation
  - Patient was oriented x 3 during the time of appointment.
  - No issues noted with patient’s orientation during the episode.
  - Patient was oriented to person and place, but was disoriented to time.
  - Patient stayed disoriented to person, place, and time during the episode and needed continuous reinforcements from the caregivers on the same.
  - Patient has a very short attention span and needs frequent reorientation to the situation.
  - Need for frequent reorientation has increased significantly during the episode.
- Memory and Forgetfulness
  - Patient’s memory has been stable with no compromise lately.
  - Patient’s memory is partially compromised, with no changes noted over the episode.
  - Patient’s memory is partially affected, with slowly increasing difficulty to recall events.
  - Patient’s memory is severely affected, with recent highly increased difficulty to recall events.
  - Memory is moderately compromised with regards to recalling recent events.
  - Patient’s memory with regards to recent events is in place, but remote memory is severely compromised.
- Slow Mentation
  - Patient has a normal pace of thought process, with difficulty only under unfamiliar conditions.
  - Patient presents with an overall slowed thought process and slowed recall of events.
  - Patient needs multiple prompts and cueing from caregivers to help recall events and needs some extra time to respond.
- Exacerbation of Episodes of Confusion in Recent Times
  - Increased frequency of episodes of confusion and disorientation reported in recent times.
  - Concentrating and thinking abilities have been increasingly declining lately.
  - Patient’s thought process has slowed down during the episode, especially after the recent episode of CVA.
  - Patient’s thought process has slowed down, after suffering a fall, during the episode.
- Psychosocial Issues
  - No psychosocial issues noted over the episode.
  - Patient has caregivers to attend for needs.
  - Patient lives alone and has no family members to attend for needs.
- Attitude
  - Patient maintained a cheerful and pleasant attitude during the time of appointment.
  - Patient is usually very responsive to caregivers.
  - Patient is hardly responsive to caregivers.
  - Patient presented with a flat affect and blank stare during the time of appointment
  - Patient frequently gets irritable and becomes aggressive with caregivers.
  - Patient appeared a little hostile during the time of appointment.
  - Occasional episodes of aggressive behavior noted/reported over the episode.
  - Patient has become increasingly irritable and hostile over the episode.
  - No changes noted with patient’s attitude and behavior over the episode.
- Does patient have history of anxiety?
  - Yes
  - No
- Anxiety
  - Patient has chronic history of anxiety.
  - Patient was diagnosed with anxiety and was started on antianxiety medications during the episode.
  - Symptoms of anxiety have been stable lately, with no gross exacerbation noted.
  - Exacerbation of symptoms of anxiety noted during the episode.
  - Increase in frequency of anxiety episodes reported in recent times.
- Causes for Exacerbation
  - No substantial reason cited for the exacerbation of anxiety episodes in recent times.
  - Exacerbation of anxiety episodes reported to be secondary to recent changes in personal life.
  - Exacerbation of anxiety symptoms reported to be secondary to recent changes in living situations.
- Changes with Antianxiety Medications
  - No changes with regards to antianxiety medications and dosages happened over the episode.
  - Changes with antianxiety medications/dosages happened during the episode, secondary to exacerbation of anxiety symptoms.
  - Patient is being closely watched for therapeutic response.
- Does patient have history of schizophrenia?
  - Yes
  - No
- Schizophrenia
  - Patient has chronic history of Schizophrenia.
  - Patient was newly diagnosed with Schizophrenia during the episode.
  - Patient presents with flat affect and is hardly responsive.
  - Patient presented with some aggressive behavior today, during the time of appointment.
  - Patient presented with on and off episodes of some aggressive behavior, during the episode.
  - Patient presents with delusions and altered thought process, with exacerbation of symptoms over the episode.
- No Exacerbation of Schizophrenia Symptoms
  - Symptoms of schizophrenia have been well controlled.
  - Thought process reportedly has been fairly balanced lately.
  - No exacerbation of schizophrenic symptoms reported in recent times.
  - Symptoms of schizophrenia have been partially controlled lately, with occasional episodes of relapse noted during the certification period.
  - No changes with medications/dosages for control of schizophrenic symptoms noted during the episode.
  - Patient is being watched closely for response to the current medications.
- Exacerbation of Schizophrenia Symptoms
  - Patient presented with relapse and exacerbation of schizophrenic symptoms over the episode.
  - Exacerbation of schizophrenic symptoms was reported to the physician.
  - Patient has been started on new medications to control symptoms of schizophrenia in recent times.
  - Changes with medications/dosages happened over the episode, for better control of relapse and exacerbation of schizophrenic symptoms.
  - Patient is being watched closely for response to changes in the medications.
- Does patient have history of depression?
  - Yes
  - No
- Depression
  - Patient has history of chronic depression.
  - Patient was diagnosed with depression over the episode.
  - Patient presents with flat affect and is hardly responsive.
  - Patient is reasonably responsive and communicative.
  - Patient is communicative only with regular caregivers and not with strangers.
  - Patient presented with occasional episodes of aggressive behavior, during the episode.
  - Patient presents with delusions and altered thought process, with exacerbation of symptoms over the episode.
- Causes for Depression
  - No defined reasons identified for patient’s depression.
  - Deteriorating personal health contributes significantly to the patient’s depression and exacerbation of symptoms during the episode.
  - Depression is secondary to loss of spouse over the episode.
  - Depression is secondary to loneliness and changes in patient’s living conditions in recent times.
- No Exacerbation of Depression Symptoms
  - Over the episode, symptoms of depression have been well controlled with current treatment.
  - Thought process reportedly has been fairly balanced lately.
  - No exacerbation of depressive symptoms reported in recent times.
  - Symptoms of depression have been partially controlled lately, with episodes of relapse noted during the certification period.
  - No changes with antidepressant medications/dosages reported in recent times.
  - Patient is being watched closely for response to the current medications.
- Exacerbation of Depression Symptoms
  - Patient presented with relapse and exacerbation of depressive symptoms in recent times.
  - Exacerbation of depressive symptoms was reported to the physician.
  - Patient has been started on new antidepressant medications in recent times.
  - Changes with antidepressant medications/dosages reported in recent times, to better control the relapse and exacerbation of depressive symptoms.
  - Patient is being watched closely for response to changes in the medications.
- Does patient have history of bipolar disorder?
  - Yes
  - No
- Bipolar Disorder
  - Patient has history of chronic bipolar disorder.
  - Patient was newly diagnosed with bipolar disorder during the episode.
  - Patient presents with flat affect and is hardly responsive.
  - Patient is reasonably responsive and communicative.
  - Patient is communicative only with regular caregivers and not with strangers.
  - Patient presented with some aggressive behavior today, during the time of appointment.
  - Patient presented with on and off episodes of some aggressive behavior, during the episode.
  - Patient presents with delusions and altered thought process, with exacerbation of symptoms over the episode.
- No Exacerbation of Bipolar Symptoms
  - Symptoms of bipolar disorder have been well controlled in recent times.
  - Thought process reportedly has been fairly balanced lately.
  - No exacerbation of bipolar symptoms reported in recent times.
  - Symptoms of bipolar symptoms have been partially controlled lately, with occasional episodes of relapse noted during the certification period.
  - No changes with medications/dosages for control of bipolar symptoms noted during the episode.
  - Patient is being watched closely for response to the current medications.
- Exacerbation of Bipolar Symptoms
  - Patient presented with relapse and exacerbation of bipolar symptoms during the episode.
  - Exacerbation of bipolar symptoms was reported to the physician.
  - Patient has been started on new medications over the episode, for better control of exacerbation of bipolar symptoms.
  - Changes with medications/dosages happened during the episode, for better control of relapse and exacerbation of bipolar symptoms.
  - Patient is being watched closely for response to changes in the medications.
- Does patient have history of sleep disturbance/insomnia?
  - Yes
  - No
- Sleep Disturbance
  - Patient has history of insomnia.
  - Patient was newly diagnosed with insomnia during the episode.
  - Insomnia is secondary to recent changes in patient’s personal life.
  - Insomnia is secondary to recent changes in patient’s living arrangements.
  - No defined reasons identified for patient’s insomnia.
  - Patient is currently on medications for insomnia.
  - Patient presented with restlessness and was very tired during the time of appointment.
- No Exacerbation of Insomnia
  - Patient reports having no disturbance with sleep pattern in recent times.
  - No exacerbation of insomnia reported in recent times.
  - Insomnia has been partially controlled lately, with on and off episodes of relapse noted during the certification period.
  - No changes with hypnotic medications/dosages for control of insomnia noted over the episode.
  - Patient is being watched closely for response to the current medications.
- Exacerbation of Insomnia
  - Patient presented with relapse and exacerbation of insomnia during the episode.
  - Exacerbation of insomnia was reported to the physician.
  - Over the episode, patient has been started on new hypnotic medications to promote sleep.
  - Changes with hypnotic medications and dosages happened during the episode, to better manage the exacerbation of insomnia.
  - Patient is being watched closely for response to changes in the medications.
- Does patient have history of seizures?
  - Yes
  - No
- Seizures
  - Patient has history of tonic-clonic seizures.
  - Patient has history of absence seizures.
  - Patient was newly diagnosed with seizures during the episode.
  - Intense tonic-clonic activity reported during the seizure episodes.
  - No motor activity reported and patient mostly blanks out during the seizure episodes.
  - No recent activation of seizure activity reported in this episode.
  - Patient is not on any anticonvulsant medications currently.
  - Patient is on oral anticonvulsants for control of seizure activity.
- No Exacerbation of Seizure Activity
  - No episodes of seizures happened during the episode.
  - Seizures have been partially controlled, with on and off episodes of relapse noted during the certification period.
  - No changes with antiseizure medications/dosages happened in recent times.
  - Patient is being watched closely for response to the current medications.
- Exacerbation of Seizure Activity
  - Patient presented with increased relapse of seizure activity over the episode.
  - Exacerbation of seizure activity was reported to the physician.
  - Patient has been started on new anticonvulsant medications during the episode.
  - Changes with anticonvulsant medications/dosages reported during the episode, to better control the exacerbation of seizure episodes.
  - Patient is being watched closely for response to changes in the medications.
- Does patient have history of Alzheimer's disease?
  - Yes
  - No
- Alzheimer’s Disease
  - Patient has chronic history of Alzheimer’s.
  - Patient was diagnosed with Alzheimer’s during the episode.
  - Patient needs 24/7 caregiver assistance to help with daily activities
  - Patient’s need for caregiver assistance has increased steeply during the episode.
  - Patient lives in a group home/facility with 24/7 caregiver assistance.
  - Patient is reasonably responsive and communicative.
  - Patient presents with flat affect and is hardly responsive.
  - Patient is communicative only with regular caregivers and not with strangers.
  - Patient needs multiple prompts and cueing from caregivers to help recall events.
- No Exacerbation of Alzheimer’s Disease Lately
  - Symptoms of Alzheimer’s have reportedly been stable in recent times.
  - Caregiver reports the patient to have some good and bad days.
  - Caregiver reports an overall slowed thought process with an increasingly slowed recall lately.
  - Thought process reportedly has been fairly balanced lately.
  - No changes with medications/dosages for treatment of Alzheimer’s happened over the episode.
  - Patient is being watched closely for response to the current medications.
- Exacerbation of Alzheimer’s Disease Lately
  - Over the episode, patient presented with increased frequency of episodes of frustration and anxiety, secondary to difficulty recalling events and people.
  - Patient needs a continuous low grade stimulatory environment.
  - Caregiver reports increased need for reminders and reorientation to task lately.
  - Exacerbation of Alzheimer’s symptoms was reported to the physician.
  - Patient has been started on new medications for management of Alzheimer’s in recent times.
  - Changes with medications/dosages for treatment of Alzheimer’s happened over the episode, to better control the exacerbation of symptoms.
  - Patient is being watched closely for response to changes in the medications
- Is patient considering other relief measures?
  - Yes
  - No
- Other Relief Measures and Counselling
  - Over the episode, patient was recommended mental health counseling sessions.
  - Patient has attended counseling sessions over the episode, by a mental health counsellor.
  - Patient reports the counseling sessions to be effective.
  - Patient reports the counseling sessions to be barely effective.
  - Patient is considering having the counseling sessions again.
  - Patient is considering changing her therapist.
  - Patient is currently attending counseling sessions by a mental health counsellor.
  - Counseling sessions to continue.
- Biofeedback
  - Over the episode, patient was recommended biofeedback sessions by a therapist.
  - Patient has attended biofeedback sessions during the episode.
  - Patient reports the biofeedback sessions to be effective.
  - Patient reports the biofeedback sessions to be barely effective.
  - Patient is considering having the biofeedback sessions again.
  - Patient is considering changing her therapist.
  - Patient is currently attending biofeedback sessions.
- Additional Information-Neuro/Emotional/Behavioral Status
- Musculoskeletal Status
- Select As Applicable
- Motor Strength
  - Motor strength is WNL in all major muscle groups.
  - Diffuse motor weakness noted in all major muscle groups during the episode.
  - Patient has improved on overall motor strength, over the episode, secondary to compliance with therapy.
- Motor Strength within WNL
  - RLE;
  - LLE;
  - RUE;
  - LUE;
  - BLE;
  - BUE;
  - all 4 extremities;
  - upper back;
  - lower back;
  - Other
- Other Muscle Groups with WNL Motor Strength
- Muscle Groups with Compromised Motor Strength
  - RLE;
  - LLE;
  - RUE;
  - LUE;
  - BLE;
  - BUE;
  - all 4 extremities;
  - upper back;
  - lower back;
  - Other
- Other Muscle Groups with Compromised Motor Strength
- Bilateral Grips
  - Bilateral grips were noted to be WNL.
  - Bilateral grips are weak, making it difficult holding the assistive device during ambulation.
  - Weak grips do not offer much support during transfers and thus contribute to fall risk.
- Location of Weak Grip Strength
  - RUE;
  - LUE;
  - BUE;
- Reasons for Weak Grip Strength
  - generalized weakness;
  - dominant side hemiparesis;
  - nondominant side hemiparesis;
  - history of stroke;
  - Other
- Other Reasons for Weak Grip Strength
- Gait
  - normal gait;
  - hemiplegic gait;
  - ataxic gait;
  - antalgic gait;
  - parkinsonian gait;
  - high stepping gait;
  - Other
- Other Types of Gait
- Balance
  - Patient is noted to have stable balance during the episode.
  - Patient's balance is compromised during the episode.
- Patient was noted to be stable with
  - no assistive device;
  - cane;
  - walker;
  - Other
- Other reasons for stable balance
- Patient's balance was compromised
  - without assistive device;
  - with cane;
  - with walker;
  - Other
- Other reasons for compromised balance
- Reasons for Compromised Balance
  - history of vertigo;
  - pain in the weight bearing joints;
  - poor motor strength in BLE;
  - muscle deconditioning;
  - prolonged hospitalization and bedrest;
  - poor support offered by the device;
  - poor compliance with assistive device use;
  - Other
- Other Reasons for Compromised Balance
- Is patient at risk for fall?
  - Yes
  - No
- Causes for fall risk
  - poor vision ;
  - morbid obesity ;
  - poor motor coordination and ataxia ;
  - noncompliance with use of assistive device ;
  - poor balance during weight bearing and ambulation ;
  - Other
- Additional causes for fall risk
- Any recent fall?
  - Yes
  - No
- Fall (s) were
  - eventful
  - uneventful
  - both eventful and uneventful
- Number of eventful falls (number only)
- Number of uneventful falls (number only)
- Number of eventful falls (number only)
- Number of uneventful falls (number only)
- Patient suffered abrasions/bruises on (name only)
- Concussion injury
  - no LOC during the fall.
  - LOC for brief time reported.
- Did patient suffer any fractures from the fall?
  - Yes
  - No
- Patient suffered fracture of (name only)
- Surgical interventions for fractures suffered
  - No active surgical interventions suggested for the fractures suffered.
  - The joint was placed in a cast and rest and immobility recommended.
  - Patient underwent an open reduction and internal fixation on the fractured site during the episode.
- Other surgical interventions for fractures suffered include
- Does patient have any weight bearing limitations?
  - Yes
  - No
- NWB- Weight bearing limitation sites
  - RLE ;
  - LLE ;
  - RUE ;
  - LUE
- WBAT- Weight bearing limitation sites
  - RLE ;
  - LLE ;
  - RUE ;
  - LUE
- Partial- Weight bearing limitation sites
  - RLE ;
  - LLE ;
  - RUE ;
  - LUE ;
- Weight in lbs allowed for partial weight limitations (number only)
- Is patient dependent on assistive devices?
  - Yes
  - No
- Assistive Device Recommendation
  - Walker
  - Cane
  - Wheelchair
  - Powered Wheelchair
  - Other
- Walker Use
  - Patient is knowledgeable with walker use and is independent at it.
  - Patient has recently started to use walker, to avert falls.
  - Recommendation for walker use was made for better stability.
  - Patient needs to be trained on walker gait.
- Cane Use
  - Patient is knowledgeable with cane use and is independent at it.
  - Patient has recently started to use cane, to avert falls.
  - Recommendation for cane use was made for better stability.
  - Patient needs to be trained on cane gait.
- Wheelchair Use
  - Patient has been wheelchair bound for long time.
  - Patient is knowledgeable with wheelchair use and is independent at using it.
  - Patient has recently started to use wheelchair and needs to be trained on maneuvering the same.
  - Patient needs caregiver assistance with wheeling.
- Powered Wheelchair Use
  - Patient has been wheelchair bound for long time.
  - Patient is knowledgeable with powered wheelchair use and is independent at using it.
  - Patient has recently started to use powered wheelchair and needs to be trained on maneuvering the same.
  - Patient needs caregiver assistance with wheeling.
- Other Assistive Devices Recommendation
- Compliance with assistive devices
  - Patient is compliant with using the assistive device.
  - Patient is partially compliant with using the assistive device.
  - Patient is noncompliant with using the assistive device.
  - Patient needs frequent reminders with using the assistive device.
- Reasons for Patient's Bedbound Status
  - prolonged illness and weakness;
  - muscle deconditioning;
  - aging;
  - Other
- Other Reasons for Patient's Bedbound Status
- Does patient have history of gout?
  - Yes
  - No
- Gouty Arthritis
  - Patient has history of gouty arthritis involving multiple small joints in the digits.
  - Patient was diagnosed with gout during the episode.
- Joints Involved in Gouty Arthritis
  - multiple weight bearing joints;
  - small joints of the digits and extremities;
  - bilateral hips;
  - bilateral knees;
  - bilateral ankles;
  - spine and vertebral joints;
  - bilateral shoulders;
  - Other
- Other Joints Involved in Gouty Arthritis
- No Recent Exacerbation of Gout
  - Patient reports no activation of joint inflammation during the episode.
  - Patient reports pain and inflammation in the joints has been stable over the episode, with no acute exacerbation.
- Recent Exacerbation of Gout
  - Multiple episodes of exacerbation of pain and inflammation in the joints happened during the episode.
  - Patient presents with poor grips, secondary to gouty arthritis in small joints of the digits.
  - Patient has limitation of ROM in small joints of the digits, secondary to the inflammation in the joints.
  - Patient currently has an active episode of gout with inflammation of multiple small joints in the digits.
  - Patient presents with pain and diffuse swelling of multiple small joints in the digits.
  - Patient presented with on and off inflammation of multiple joints during the episode, thus limiting ROM and activity.
- Medications Changes for Gout
  - Patient/caregiver reports no changes with regards to medications/doses for management of gout during the episode.
  - Patient is currently on medication for management of gout.
  - Patient was started on medication, for improved control of gout during the episode.
  - Patient's dose for gout medications was changed recently.
  - Patient was discontinued on medications for gout lately.
- Reasons for Dose Changes with Gout Medications
  - goals met;
  - improved control of gout symptoms;
  - poor therapeutic response;
  - exacerbation of gout symptoms;
  - bothersome side-effects of the medication;
  - allergic response;
  - Other
- Other Reasons for Dose Changes with Gout Medications
- Reasons for Discontinuation with Gout Medications
  - goals met;
  - improved control of gout symptoms;
  - poor therapeutic response;
  - exacerbation of gout symptoms;
  - bothersome side-effects of the medication;
  - allergic response;
  - Other
- Other Reasons for Discontinuation with Gout Medications
- Knowledge Regarding Low Purine Diet
  - Patient/caregiver is poorly knowledgeable about low purine diet.
  - Patient/caregiver is knowledgeable about low purine diet.
  - Patient/caregiver needs instructions regarding low purine diet. SN to instruct the patient/caregiver on the same.
- Compliance With Low Purine Diet
  - compliant
  - moderately compliant
  - poorly compliant
- Does patient have history of fibromyalgia?
  - Yes
  - No
- Fibromyalgia
  - Patient has history of fibromyalgia involving major muscle groups in the extremities.
  - Patient was diagnosed with fibromyalgia during the episode, affecting major muscle groups and consequently, affecting activity and ambulation.
- Symptoms of Fibromyalgia
  - diffuse skeletal pain;
  - fatigue;
  - sleep disturbances;
  - anxiety;
  - depression;
  - Other
- Other Symptoms of Fibromyalgia
- No Recent Exacerbation of Fibromyalgia
  - Patient presented with no exacerbation of fibromyalgia during the episode.
  - Patient reports pain and inflammation in the joints has been stable lately, with no acute exacerbation during the episode.
- Recent Exacerbation of Fibromyalgia
  - Patient has limitation of ROM in all the extremities, secondary to history of fibromyalgia.
  - Patient currently has an active episode of fibromyalgia, involving major muscle groups.
  - Patient had an exacerbation of fibromyalgia during the episode and currently presents with diffuse limitation of ROM.
  - Patient reports on and off episodes of exacerbation of fibromyalgia during the episode, with diffuse pain and inflammation, thus limiting activity and ambulation.
  - Multiple episodes of exacerbation of pain and inflammation in the joints happened during the episode.
- Medication Changes for Fibromyalgia
  - No changes with regards to pain medication/dosage happened during the episode.
  - Changes with regards to medication/dosage happened during the episode, to manage the exacerbation of fibromyalgia.
- Does patient have history of osteoarthritis?
  - Yes
  - No
- Osteoarthritis
  - Patient has history of osteoarthritis involving multiple weight bearing joints.
  - Patient was diagnosed with osteoarthritis involving multiple weight bearing joints during the episode.
- Joints Involved in Osteoarthritis
  - multiple weight bearing joints;
  - small joints of the digits and extremities;
  - bilateral hips;
  - bilateral knees;
  - bilateral ankles;
  - spine and vertebral joints;
  - bilateral shoulders;
  - Other
- Other Joints Involved in Osteoarthritis
- No Recent Exacerbation of Osteoarthritis
  - Patient presented with no exacerbation of osteoarthritis during the episode.
  - Patient presented with stable pain and inflammation in the joints during the episode, with no acute exacerbation.
- Recent Exacerbation of Osteoarthritis
  - Patient has limitation of ROM in weight bearing joints, secondary to the inflammation in the joints.
  - Multiple episodes of exacerbation of pain and inflammation in the joints happened during the episode.
  - Patient had an exacerbation of osteoarthritis during the episode and currently presents with diffuse limitation of ROM in weight bearing joints.
  - Patient currently has exacerbation of arthritis, involving multiple weight bearing joints.
  - Patient presents with pain and diffuse swelling of weight bearing joints.
  - Patient presented with on and off episodes of exacerbation of arthritis involving multiple joints during the episode, with diffuse pain and inflammation, thus limiting activity and ambulation.
  - Patient is currently using an ice pack to contain the swelling in weight bearing joints.
- Medications Changes for Osteoarthritis
  - Patient/caregiver reports no changes with regards to medications/doses for management of osteoarthritis during the episode.
  - Patient is currently on medication for management of osteoarthritis.
  - Patient was started on medication during the episode., for improved control of osteoarthritis.
  - Patient's dose for osteoarthritis medications was changed recently.
  - Patient was discontinued on medications for osteoarthritis lately.
- Reasons for Dose Changes with Osteoarthritis Medications
  - goals met;
  - improved control of pain and inflammation;
  - poor therapeutic response;
  - exacerbation of pain and inflammation;
  - bothersome side-effects of the medication;
  - allergic response;
  - Other
- Other Reasons for Dose Changes with Osteoarthritis Medications
- Reasons for Discontinuation with Osteoarthritis Medications
  - goals met;
  - improved control of pain and inflammation;
  - poor therapeutic response;
  - exacerbation of pain and inflammation;
  - bothersome side-effects of the medication;
  - allergic response;
  - Other
- Other Reasons for Discontinuation with Osteoarthritis Medications
- Does patient have history of rheumatoid arthritis?
  - Yes
  - No
- Rheumatoid Arthritis
  - Patient has history of rheumatoid arthritis involving multiple joints, especially small joints of extremities.
  - Patient was diagnosed with rheumatoid arthritis involving multiple joints during the episode.
  - Patient currently has an episode of RA activation and inflammation of multiple joints.
- Joints Involved in Rheumatoid Arthritis
  - multiple weight bearing joints;
  - small joints of the digits and extremities;
  - bilateral hips;
  - bilateral knees;
  - bilateral ankles;
  - spine and vertebral joints;
  - bilateral shoulders;
  - Other
- Other Joints Involved in Rheumatoid Arthritis
- No Recent Exacerbation of Rheumatoid Arthritis
  - Patient presented with no exacerbation of rheumatoid arthritis during the episode.
  - Patient presented with stable pain and inflammation in the joints during the episode, with no acute exacerbation.
- Recent Exacerbation of Rheumatoid Arthritis
  - Patient has limitation of ROM in multiple joints, secondary to the inflammation in the joints.
  - Patient had an exacerbation of rheumatoid arthritis during the episode and currently presents with diffuse limitation of ROM in multiple joints.
  - Patient presents with pain and diffuse swelling of multiple joints in the extremities.
  - Patient presented with on and off episodes of exacerbation of arthritis involving multiple joints during the episode, with diffuse pain and inflammation, thus limiting activity and ambulation.
  - Patient is currently using an ice pack to contain the swelling in the inflamed joints.
  - Multiple episodes of exacerbation of pain and inflammation in the joints happened during the episode.
- Medications Changes for Rheumatoid Arthritis
  - Patient/caregiver reports no changes with regards to medications/doses for management of rheumatoid arthritis during the episode.
  - Patient is currently on medication for management of rheumatoid arthritis.
  - Patient was started on medication, for improved control of rheumatoid arthritis during the episode.
  - Patient's dose for rheumatoid arthritis medications was changed recently.
  - Patient was discontinued on medications for rheumatoid arthritis lately.
- Reasons for Dose Changes with Rheumatoid Arthritis Medications
  - goals met;
  - improved control of pain and inflammation;
  - poor therapeutic response;
  - exacerbation of pain and inflammation;
  - bothersome side-effects of the medication;
  - allergic response;
  - Other
- Other Reasons for Dose Changes with Rheumatoid Arthritis Medications
- Reasons for Discontinuation with Rheumatoid Arthritis Medications
  - goals met;
  - improved control of pain and inflammation;
  - poor therapeutic response;
  - exacerbation of pain and inflammation;
  - bothersome side-effects of the medication;
  - allergic response;
  - Other
- Other Reasons for Discontinuation with Rheumatoid Arthritis Medications
- Does patient have history of Parkinson's disease?
  - Yes
  - No
- Parkinson’s Disease
  - Patient has history of Parkinson’s disease.
  - Patient was diagnosed with Parkinson’s disease over the current episode.
  - Parkinson’s is in an early stage and no active symptoms were noted over the episode.
- Active Parkinson’s Symptoms
  - Patient presented with dyskinesia and tremors during the episode.
  - Rigidity of posture with limited ROM in the extremities is very profound.
  - Patient presented with difficulty initiating movement and maintaining a smooth pace during the execution of activity.
  - Tremor is significant during rest and settles down with activity.
- No Exacerbation of Parkinson’s Symptoms
  - Dyskinesia and tremor have been stable and well controlled with current treatment during the episode.
  - Dyskinesia and tremor have been partially controlled, with occasional episodes of exacerbation lately.
  - No changes with antiparkinsonian medications and dosages reported in recent times.
  - Patient is being watched closely for response to the current medications.
- Exacerbation of Parkinson’s Symptoms
  - Over the episode, patient presented with exacerbation of dyskinesia and tremors.
  - Exacerbation of dyskinesia and tremors compromised patient’s independence with ADL performance.
  - Exacerbation of parkinson’s symptoms was reported to the physician.
  - Patient has been started on new medications for control of Parkinson’s exacerbation lately.
  - Changes with medications/dosages happened over the episode, to better control the exacerbation of dyskinesia and tremors.
  - Patient is being watched closely for response to changes in the medications.
- Does patient have history of multiple sclerosis?
  - Yes
  - No
- Multiple Sclerosis
  - Patient has history of multiple sclerosis.
  - Patient was recently diagnosed with multiple sclerosis.
- Symptoms of Multiple Sclerosis
  - Patient presented with dyskinesia and tremors during the episode.
  - Rigidity of posture with limited ROM in the extremities is very profound.
  - Patient is quadriplegic and limited to wheelchair, secondary to history of multiple sclerosis.
  - Patient presents with pain, secondary to diffuse spasticity of muscles.
  - Diffuse muscle weakness and wasting noted, secondary to long standing multiple sclerosis.
  - Patient has difficulty with initiating movement and maintain smooth pace during the execution of activity.
  - Patient vision is compromised secondary to multiple sclerosis affecting the optic nerve.
- No Relapse of Multiple Sclerosis Lately
  - No active symptoms of multiple sclerosis noted or reported.
  - No exacerbation of dyskinesia and tremors reported in recent times.
  - Symptoms of multiple sclerosis have been in remission lately, with no episodes of relapse.
- Relapse of Multiple Sclerosis
  - Patient reports exacerbation of dyskinesia and tremors in recent times.
  - Patient/caregiver reports progressive muscle weakness during the episode.
  - Exacerbation of pain, secondary to spasticity in the muscles reported over the episode.
  - Exacerbation of multiple sclerosis symptoms was reported to the physician.
  - Patient presents with diffuse muscle wasting.
- Management Measures for Multiple Sclerosis
  - Patient periodically undergoes plasma exchange.
  - Patient/caregiver reports no changes with regards to medications/doses for management of multiple sclerosis during the episode.
  - Patient is currently on medication for management of multiple sclerosis.
  - Patient was started on medications for improved control of symptoms of multiple sclerosis during the episode..
  - Patient's dose with medications was changed recently.
  - Patient was discontinued on medications for management of multiple sclerosis during the episode..
- Reasons for Dose Changes with Medications for Multiple Sclerosis
  - goals met;
  - improved control of symptoms of multiple sclerosis;
  - symptoms of multiple sclerosis in remission;
  - poor therapeutic response;
  - exacerbation of symptoms of multiple sclerosis;
  - bothersome side-effects of the medication;
  - allergic response;
  - Other
- Other Reasons for Dose Changes with Medications for Multiple Sclerosis
- Reasons for Discontinuation with Medications for Multiple Sclerosis
  - goals met;
  - improved control of symptoms of multiple sclerosis;
  - symptoms of multiple sclerosis in remission;
  - poor therapeutic response;
  - exacerbation of symptoms of multiple sclerosis;
  - bothersome side-effects of the medication;
  - allergic response;
  - Other
- Other Reasons for Discontinuation with Medications for Multiple Sclerosis
- Does patient have complaint of hemiplegia/quadriplegia/paraplegia?
  - Yes
  - No
- History of Paralysis
  - quadriplegia;
  - hemiplegia;
  - paraplegia;
  - quadriparesis;
  - hemiparesis;
  - paraparesis;
  - Other
- Other History of Paralysis
- Location of Muscle Weakness
  - dominant side of body;
  - non-dominant side of body;
  - right side of body;
  - left side of body;
  - diffuse truncal and x 4 extremities;
  - BLE;
  - Other
- Other Location of Muscle Weakness
- Reasons for Muscle Weakness and Paralysis
  - history of CVA;
  - history of multiple sclerosis;
  - history of cerebral palsy;
  - traumatic spine injury;
  - traumatic brain and spinal cord injury;
  - Other
- Other Reasons for Muscle Weakness and Paralysis
- Presentation of Patient
  - Paralysis of the muscles is spastic, with contractures and increased tone of the muscles in involved extremities.
  - Contractures of the muscles resulted in limitation of ROM with multiple joints in affected extremities.
  - Patient has history of undergoing surgery for contracture release, to facilitate ROM in the involved extremities.
  - Paralysis of the muscles is flaccid, with reduced muscle tone and the involved muscles being limp.
  - Flaccidity with diffuse muscle wasting noted in the affected extremities.
- Does patient complain of muscle spasm?
  - Yes
  - No
- Muscle Spasms
  - Patient complains of no muscle spasms limiting ROM in the extremities.
  - Patient reports diffuse muscle spasms on and off, limiting ROM in the extremities.
  - Patient started presenting with diffuse muscle spasms during the episode.
  - No exacerbation of muscle spasms reported during the certification period.
  - Exacerbation of muscle spasms reported during the episode.
- Muscle Relaxants
  - No changes were reported with regards to dose of muscle relaxant over the episode.
  - Changes were made with regards to dose of muscle relaxant over the episode.
  - Patient was recently started on muscle relaxant, to help relieve spasms.
- Did the patient undergo any joint replacement currently?
  - Yes
  - No
- Patient recently underwent replacement of the
  - left knee ;
  - right knee ;
  - left hip ;
  - right hip ;
  - left shoulder ;
  - right shoulder ;
  - Other
- Other joint replacements
- ROM in the surgical joint
  - ROM and stability in the surgical joint is WNL.
  - ROM and stability in the surgical joint is compromised.
  - ROM and joint stability is being worked on.
  - Therapy recommendation was made.
  - ROM and stability in the surgical joint is established, secondary to therapy during the episode.
- Independence with ADLs
  - Patient’s endurance and independence with ADL performance has improved during the episode.
  - Patient is independent with ADL performance for the most part, hardly needing any assistance from caregivers.
  - Patient continues to be moderately independent with ADL performance during the episode and needs caregiver assistance with some.
  - Patient was independent with ADL performance until late in this episode, but increasingly grew weaker in the last 2 – 3 weeks of the episode, needing assistance from caregiver.
  - Patient was dependent on caregiver assistance with regards to ADL performance during the initial part of the episode, but gained motor strength secondary to therapy, and currently, needs lesser caregiver assistance.
  - Patient continues to be completely dependent on caregiver assistance for ADL performance.
- Caregiver Assistance with ADLs
  - Caregiver needs to be trained on assisting the patient with ADL performance.
  - Caregiver is independent with assisting the patient on ADL performance.
  - No reliable caregiver is available for assisting with ADL performance.
  - Caregiver’s physical condition would not allow assisting the patient with ADL performance.
  - Caregiver assistance is only occasional and partial.
- Home Health Aide
  - HHA service was offered, but patient denied.
  - HHA to be provided by the agency for assisting with ADL performance.
  - HHA service to be discontinued.
- Reasons for Limitation of ADL Performance
  - Patient’s demented status limits independence with ADL performance.
  - Patient’s hemiplegic status limits independence with ADL performance.
  - Patient’s quadriplegic status limits independence with ADL performance.
  - Patient’s history of multiple sclerosis and motor incoordination limit independence with ADL performance.
  - Patient’s history of back pain and episodes of exacerbation during the certification period, limit independence with ADL performance.
  - Pain and diffuse spasms limit ambulation and activities, thus limiting independence with ADL performance.
  - Diffuse motor weakness confines the patient to wheelchair, thus limiting independence with ADL performance.
  - Limited endurance confines the patient to bedrest, thus limiting independence with ADL performance.
- Any therapy recommendations?
  - Yes
  - No
- Therapy Recommendations
  - PT to be recommended.
  - OT to be recommended.
  - PT and OT to be recommended.
  - ST to be recommended.
  - Patient was discharged from rehab recently with therapy recommendation.
  - Therapy was provided during the episode.
- Therapy Goals and Progress
  - Therapy goals to be established.
  - Goals of therapy were completely met.
  - Patient has attained maximum potential with the regards to therapy goals established.
  - Goals of therapy were partially met and therapy to continue.
  - Therapy sessions are in progress, working towards the established goals.
  - Therapy discharged the patient recently.
- HEP Compliance
  - Recommendations for HEP were made.
  - Patient reports compliance with the HEP established.
  - Compliance with HEP established was reported on and off.
  - Patient is noncompliant with the HEP established.
  - Patient was instructed upon compliance with the HEP established.
- Additional Information-ADL/IADL
- Reasons for Notifying Physician's Office
- Select As Applicable
- Reasons for Notifying Physician's Office
  - Elevated blood pressure ;
  - Low blood pressure ;
  - Elevated blood sugar ;
  - Low blood sugar ;
  - Low oxygen saturation ;
  - Exacerbation of SOB ;
  - Symptoms of UTI ;
  - Productive cough ;
  - Symptoms of chest infection ;
  - Fall suffered ;
  - Exacerbation of pain ;
  - Lack of bowel movement for last 3 days ;
  - Dizziness and confusion ;
  - Risk for skin integrity noted ;
  - Signs and symptoms of wound infection ;
  - Other
- Other Reasons for Notifying Physician's Office
- Reasons for ER Visits and Hospitalization
- Select As Applicable
- Reasons for ER Visits/Hospitalization
  - Elevated blood pressure ;
  - Episode of stroke ;
  - Hypotension and episodes of confusion ;
  - Elevated blood sugar and episodes of confusion ;
  - Low blood sugar and episodes of confusion ;
  - Low oxygen saturation ;
  - Exacerbation of SOB ;
  - Exacerbation of COPD ;
  - UTI ;
  - Episode of pneumonia ;
  - Symptoms of chest infection ;
  - Motor weakness and recurrent falls suffered ;
  - Exacerbation of pain ;
  - Fecal impaction and lack of bowel movement for a week ;
  - Dehydration and episodes of confusion ;
  - Other
- Other Reasons for ER Visits/Hospitalization
- Reasons for Recertification to Home Health Care
- Select As Applicable
- Patient is being recertified to home health service for
  - Poorly controlled HTN ;
  - Moderately controlled HTN ;
  - Recurrent hypotensive episodes ;
  - Continuing episodes of dizziness ;
  - Exacerbation of arrhythmias ;
  - Moderately controlled arrhythmias ;
  - Poorly controlled CHF ;
  - Moderately controlled CHF;
  - Poorly controlled pain ;
  - Moderately controlled pain ;
  - Exacerbation of COPD ;
  - Moderately controlled COPD ;
  - Recurrent GERD episodes ;
  - Poorly managed blood sugars ;
  - Moderately controlled blood sugars ;
  - Continuing wound care ;
  - Poorly managed constipation ;
  - Moderately controlled constipation ;
  - Poorly managed BPH and urinary symptoms ;
  - Moderately controlled BPH and urinary symptoms ;
  - Increased risk for UTI ;
  - Multiple UTIs lately ;
  - Poorly managed depression ;
  - Moderately controlled depressive symptoms ;
  - Poorly managed anxiety ;
  - Moderately controlled anxiety symptoms ;
  - Continuing muscle weakness ;
  - Increased fall risk ;
  - Limitation of ROMs ;
  - Poor endurance and exercise tolerance ;
  - Other
- Patient needs continuing instructions regarding
  - patient’s health conditions ;
  - medications ;
  - compliance with dietary recommendations ;
  - preventing fall risk ;
  - compliance with HEP established by therapist ;
  - insulin training ;
  - colostomy training and bag changes ;
  - urostomy training and bag changes ;
  - inhaler and nebulizer use ;
  - coumadin precautions ;
  - Lovenox training ;
  - smoking cessation ;
  - pacemaker precautions ;
  - dialysis training ;
  - Other
- Other Reasons for Recertification
- Additional Patient Information

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

Recertification Template

Patient's Health History

Select As Applicable

Pain Information

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Respiratory Status

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Integumentary Status

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Endocrine Status

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Cardiovascular Status

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GU

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GI

Select As Applicable

Nutrition

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Neuro/Emotional/Behavioral Status

Select As Applicable

Musculoskeletal Status

Select As Applicable

Reasons for Notifying Physician's Office

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Reasons for ER Visits and Hospitalization

Select As Applicable

Reasons for Recertification to Home Health Care

Select As Applicable