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Home HealthCare Documentation Forms

Home Healthcare Documentation Forms Now you can generate similar detailed and comprehensive skilled nursing narrative for various health conditions using our customizable skilled nursing documentation templates.  Sign up know more!! #1 Reason(s) for Home Health Admission PICC Line Patient is a 62-year-old female who was diagnosed with MRSA pneumonia on 11/20/2010. Patient was admitted to XXX and was on antibiotics. Patient was discharged on 11/25/2010 with PICC line and an order for IV antibiotics to [...]

Home Health Paperwork Example

Home Health Paperwork Example Now you can generate similar detailed and comprehensive skilled nursing narrative for various health conditions using our customizable skilled nursing documentation templates. Sign up know more!! #1 Reason(s) for Home Health Recertification UTI Uncontrolled Blood Pressure Patient presented with burning, frequency, and urgency around 08/14/2011 and was seen by Dr. A on 08/16/2011. Patient was diagnosed with UTI and was started on SMZ-TMP 800/160 mg 1 tablet twice daily, on 08/16/2011. [...]

Home Health Documentation Templates

Home Health Documentation Templates Now you can generate similar detailed and comprehensive assessment narrative for various health conditions using our customizable and guided OASIS templatese.  Sign up know more!! #1 Reason(s) for Home Health Recertification Uncontrolled Blood Pressure Declining Renal Status GERD Patient's blood pressures have not been in good control in the last certification period with systolic ranging between 128 - 157. 3 systolic readings on SN notes were in the 150s in the [...]

OASIS Assessment Templates

OASIS Assessment Narrative Templates Now you can generate similar detailed and comprehensive assessment narrative for various health conditions using our customizable and guided OASIS templates.  Sign up know more!! #1 Reason(s) for Home Health Recertification Diminishing Response to Neuro- Emotional Status Increasing Frequency of Urinary Incontinence Patient appeared very passive, calm, and hardly responsive. He appeared a little confused with regards to orientation of his room, while walking back in from the restroom. Episodes of [...]

Nursing Assessment Documentation Templates

Nursing Assessment Documentation Templates Now you can generate similar detailed and comprehensive assessment narrative for various health conditions using our customizable and guided OASIS templatese.  Sign up know more!! #1  Reason(s) for Home Health Recertification Poorly managed BP Reported to the Physician Noncompliance with Dietary Recommendations Noncompliance with Doctor Visits Heart sounds were noted to be regular. On SN visits, systolic blood pressure varied between 108 - 150 and diastolic blood pressure varied between 60 [...]

Home Health Skilled Nursing OASIS Assessment Templates

Home Health Skilled Nursing OASIS Assessment Templates This post provides home health skilled nursing OASIS assessment templates for writing OASIS assessment note for Start of Care and Recertification Evaluation in home healthcare setting. We have listed the reasons for patient's admission assessment and based on those reasons we have built a summary which will explain and justify the need for admitting the patient to home healthcare services. Home Health Skilled Nursing OASIS Assessment Templates-Start of Care [...]

Nursing Narrative Note

Nursing Narrative Note Examples Now you can generate similar detailed and comprehensive skilled nursing narrative for various health conditions using our customizable skilled nursing documentation templates.  Sign up know more!! #1  Reason(s) for Home Health Recertification Un-resolving Pain Episodes Sleep Disturbances Un-resolving GERD Comprehensive home visit SN assessment and evaluation of all of patient's body systems, needed for recertification to home health services for episode period 09/03/2011 - 10/31/2011. Patient has a past medical history [...]

Nurse Teaching on Foods to Avoid on Pureed Diet

Foods to Avoid on a Pureed Diet Patient/caregiver was educated foods that should be avoided on a pureed diet. Avoid all whole fruits on pureed diet. Puree or mash the fruits completely into a smooth consistency. Make sure there is no pulp or any lumps or seeds or pieces of hard skin or string-like fibers in the pureed fruit before eating. Avoid all whole bakery products on pureed diet. Bakery products, such as, bread and [...]

Nurse Teaching on Causes of Constipation

Common Causes of Constipation Patient/caregiver was educated on common causes of constipation are listed below- Low amount of fiber in the diet: Lack of fiber in the diet slows down the movement of waste material or feces in the large intestine. Consequently, more water is absorbed from the feces and the stool becomes hard. Low intake of water: Low intake of fluid also slows down the movement of waste material or feces in the large intestine. Consequently, [...]

Nurse Teaching on Signs and Symptoms of Hypertension

Signs and Symptoms of Hypertension Patient/caregiver was educated on signs and symptoms of hypertension as below: Vision problems: Progressive damage to blood vessels in the retina, due to unresolved elevated blood pressure, can result in retinal bleeding, compromised blood supply to the retinal tissue, and retinal damage, thus affecting the visual function. This can lead to diminishing vision and in severe cases, even result in complete vision loss and blindness. Chest pain: Chronic unresolved elevated [...]

Nurse Teaching on Insulin Resistance

Insulin Resistance When blood glucose levels rise after a meal, the pancreas releases Insulin into the blood. Insulin helps transport glucose in the blood into the cells and tissues throughout the body. Insulin helps cells in the muscle, fat, and liver absorb glucose from the bloodstream. When the glucose is transported from the blood to tissues, the blood glucose levels fall. Insulin stimulates the liver and muscle tissue to store excess glucose. The stored form [...]

Nurse Teachings on Contraindications for Paraflex

  Contraindications for Paraflex Use Patient/caregiver was educated on contraindications for Paraflex as below: Do not take Paraflex, if you ever manifested any allergic responses to intake of paraflex or any other medications belonging to the group of skeletal muscle relaxants, such as, methocarbamol and baclofen. In the event of an allergic response with any of these medications, check with your physician regarding your safety with intake of paraflex. Paraflex could interact with a number of [...]

Nurse Teaching on Precautions for ACE Inhibitors

Precautions Need to be Observed while Taking ACE Inhibitors Patient/caregiver was educated on precautions to be observed while taking ACE inhibitors as follows: Drink 2.5 liters to 3 liters of fluid every day, as ACE inhibitors tend to cause loss of fluid volume and consequently, dehydration. If fluid is restricted in an individual for reasons, such as, congestive heart failure or dialysis dependent status, compliance to the recommendation made is very important. Be aware of [...]

Nurse Teaching on Inhalers

Process to Use a Spacer with Inhaler Patient/caregiver was educated on the process steps to use spacer with inhaler as below: Remove the cap from your inhaler, and from your spacer, if it has one Shake the inhaler well before use (3-4 shakes) Put the inhaler into the spacer Always, check the expiration date on the inhaler before using it. Shake the inhaler well for 5 seconds before every use. Take the cap off the [...]

Nurse Teaching on Contraindications for Ferrous Sulfate Iron Supplement

Contraindications For Using Ferrous Sulfate Iron Supplement Patient/caregiver was educated on contraindications for using Ferrous Sulfate iron supplement as below- Do not take Ferrous sulfate, if you ever manifested any allergic responses to intake of the ferrous sulfate iron supplement. In the event of history of an allergic response with ferrous sulfate or any preparations containing iron, check with your physician regarding your safety with intake of ferrous sulfate iron supplement. Phenylalanine is an amino [...]

Nurse Teaching on Acute Respiratory Distress Syndrome (ARDS)

Acute Respiratory Distress Syndrome (ARDS) Patient/caregiver was educated on Acute Respiratory Distress Syndrome also known as ARDS as follows: Acute Respiratory Distress Syndrome also known as ARDS is a condition in which there is fluid built up in the alveoli of the lungs, secondary to injury to the lung. Usually, alveoli are the sites for gas exchange in the lungs. Since, the alveoli are filled with fluid in a patient with ARDS, the gas exchange is [...]

Nurse Teaching on Baclofen Uses

Therapeutic Uses of Baclofen Patient/caregiver was educated on therapeutic uses of baclofen as below: Amyotrophic lateral sclerosis (ALS): Motor nerves originate in the brain and travelling through the spinal cord, reach the various muscles throughout the body, thus conducting the impulse to the muscles. ALS is a condition in which there is progressive degeneration of the motor nerves controlling the activity of the various muscles. Progressive degeneration of the motor nerves contributes to altered and compromised [...]

Nurse Teaching on Precautions for Amoxapine

Precautions to be observed while taking Amoxapine Patient/caregiver was educated on precautions to be observed while taking Amoxapine as follows: Follow closely on the expiration date of the medication. If using a pillbox, check the expiration date on the medication container every time you fill the pillbox. If you are taking this medication for longer periods of time, set enough reminders on your phone for medication pick-up. You can have a reminder 10 days ahead, [...]

Home Health Skilled Nursing Documentation Example

Home Health Skilled Nursing Documentation Example This post provides skilled nursing documentation example for writing assessment note for Resumption of Care and Start of Care in home healthcare setting. We have listed the reasons for patient's hospitalization. Based on those reasons, we have built a summary which can explain and justify the need for resumption of care for home healthcare patient services. Home Health Skilled Nursing Documentation Example - Resumption of Care Example 1 Reason(s) [...]

Nurse Teaching on Management of Ingrown Toenails

Measures to Manage and Prevent Ingrown Toenail Development Patient/caregiver was educated on measures to manage and prevent ingrown toenail development as follows: Avoid wearing shoes with too big heels and narrow toe boxes. This can provide better arch support and avoid undue pressure and compression of toes, thus helping to prevent injury and ingrowing of toenail. Always wear properly fitting shoes, with appropriate room in the toe box, to accommodate all the toes without any [...]

Nurse Teaching on Side Effects of Citalopram

Side Effects of Using Citalopram Patient/caregiver was educated on side effects of using Citalopram as below: General allergic reactions: Citalopram use can result in general allergic reactions, such as, skin rashes, hives, and itching. Some patients can present with symptoms of severe allergic and anaphylactic response with citalopram, such as, difficulty breathing, swelling of face, lips, throat, and tongue, with consequent difficulty breathing. Seek emergency medical help for such findings, especially with difficulty breathing, for any appropriate [...]

Nurse Teaching on Side Effects of Dutasteride

Nurse Teaching on Side Effects of Dutasteride Nurse educated the patient/caregiver on side effects of using Dutasteride as below: General allergic reactions: Dutasteride use can result in general allergic reactions, such as, skin rashes, hives, and itching. Some patients can present with symptoms of severe allergic and anaphylactic response with the medication, such as, difficulty breathing, swelling of face, lips, throat, and tongue, with consequent difficulty breathing. Seek emergency medical help for such findings, especially with [...]

Nurse Teaching on Precautions for Temazepam

Nurse Teaching on Precautions to be observed while taking Temazepam Nurse educated the patient/caregiver on precautions to be observed while taking Temazepam as below: Take Temazepam as ordered by your physician. This medication can induce some nausea and vomiting, when taken on empty stomach. Taking Temazepam with some food or snack can help avoid these unpleasant gastrointestinal symptoms. Follow closely on the expiration date of the Temazepam medication. If using a pillbox, check the expiration [...]

Nurse Teaching on Polycystic Kidney Disease (PKD)

Nurse Teaching on Polycystic Kidney Disease (PKD) Nurse educated the patient/caregiver on polycystic kidney disease (PKD) as follows: Polycystic kidney disease (PKD) is a condition in which the kidneys develop numerous small sacs called cysts. This is an inherited disorder and can involve other organs, such as liver, pancreas, and brain affecting the function of all organs involved. These cysts are thin walled sacs, filled with fluid. These cysts progressively increase in size. All the [...]

Nurse Teaching on Foods to Avoid on a Low Sodium Diet

Nurse Teaching on Foods to Avoid on a Low Sodium Diet Nurse educated the patient/caregiver on foods to avoid while following a low sodium diet- Salt can act as a preservative, increase the shelf life of food items significantly, and so, is liberally added to many frozen meals and canned foods. Avoid all frozen meals and canned vegetables due to their high added salt content on a low sodium diet. Choose to have your meals [...]