Home Health Care Documentation
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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 be administered twice daily for 8 days. Patient past health history includes CA of hypopharynx and patient underwent radio and chemo for the same. Patient is currently on trach as an outcome of the CA hypopharynx for the past 5 years. Patient is independent with trach management. Patient reports her appetite to be fair. Patient’s has a very low body weight and has been placed on Jevity, a high protein diet for management. No issues reported with bowel movements. Patient has a follow up appointment with Dr. A, PCP on 12/04/2010 and with Dr. B, pulmonary specialist on 12/01/2010.Patient and family were instructed regarding the flush protocol and guidelines to manage the PICC line. Patient recall of instructions was only 25%. Patient was also provided written instructions regarding the same. Patient to be followed up further.
Reason(s) for Home Health Recertification
- Unresolved low back pain
- Motor weakness
- Diminishing skin turgor
Patient’s low back pain is yet uncontrolled, limiting ambulation and weight bearing. Home health service to continue for SN to educate the patient on alternative pain management measures, close follow-up regarding deterioration of pain, and report accordingly for any necessary changes in management measures. Patient also needs to be educated further on GERD prevention measures, as exacerbation is reported. Patient has very poor grips in BUE. Patient needs assistance to assume a standing posture, as the grips are very poor and does not enable her to hold on to support. OT referral is being sent to improve the strength in upper arms and grips. Patient is mostly wheelchair bound. She walks with assistance for very short distances. She will be taken for a walk to the end of street every day, which could be a 200 feet distance. She has a stooped posture on standing. Her rigidity secondary to Parkinson’s limits her mobility and ROM. Has mild resting tremor in the fingers. Patient has mild difficulty initiating a movement. Motor strength all over noted to be weak. Caregivers available to provide assistance with ADL/IADLs. Skin turgor is poor. Tenting noted. Caregiver reports that she forgets to drink.
Reason(s) for Home Health Admission
- Supplemental Oxygen
Patient is a 56-year-old male, who has history of progressive neuronal disorder affecting the diaphragm, leading to diaphragmatic paralysis. Patient reported today that he was diagnosed with the disorder about 2 years ago and the condition deteriorated gradually with his diaphragm almost getting completely paralyzed. A part of the left dome of diaphragm is still functional. Overall breath sounds are diminished, except the left upper lobe, posteriorly. Patient reports no family history of neuromuscular disorders. Patient was started on intermittent Oxygen at 5 LPM about one year ago. Now, it was changed to continuous Oxygen at 5 LPM. Patient will be on Bi-PAP during the night. Patient reports having had an exacerbation of respiratory distress about 10 days ago and was hospitalized. Patient was discharged from XXX 2 days ago. Patient currently is under the care of pulmonologist; Dr. A. Pulse oximetry today was at 98% with the patient on Oxygen at 5 LPM. Patient presents with some anxiety and reports some insomnia during the night, affecting his quality of life. Patient’s other health history includes HTN and is on valsartan and diuretics for management. Patient also has history of gastric ulcer and GERD and is on Sucralfate and Famotidine for relief. Patient reports exacerbation of reflux symptoms in recent times, necessitating addition of Omeprazole to the already continuing regimen. Patient does not report any recent respiratory infections. Patient’s activity is very limited due to the poor Oxygen supply, secondary to diaphragmatic paralysis.