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 last 60 days. Patient does not have a cuff and does not take a reading every day. Patient was instructed to get a cuff and have a reading everyday with log maintenance. Patient was started recently on Nifedipine and Amlodipine dose was also changed for better management of BP. Patient saw Dr. A, her nephrologist, last on 09/26/2012. Patient also reports declining renal function in recent times as she was told during a recent visit to Dr. A. Recent medication changes with her antihypertensives are the outcomes of her visits to Dr. A. Next visit is in another 3 months. Patient’s poorly managed blood pressures could be secondary to her declining renal status. Reports swelling of feet sometimes, none noted today though. Patient saw her PCP, Dr. B, about 3 weeks ago. Next visit is after another 2 months. Patient was also started on Nifedipine ER 24hr 30 mg 1 tablet once daily, after this visit. Appetite is reportedly fair. Constipation is not an issue. Episodes of GERD still bother her. Patient needs continued home health nursing visits for patient education regarding renal diet. GERD prevention measures, and management of her BP.

 

#2

Reason(s) for Home Health Recertification

  • Fall Due to Confusion and Hypotension

Patient had one visit to his PCP in the last 2 months. About one month ago, patient had a fall in the bathroom, losing his balance. The fall was uneventful externally. But, he hurt his right knee in the fall and he dragged himself out of the restroom on his knee as he was unable to get up, as caregiver reports. Since then, the right knee and foot get swollen sometimes. Mild swelling of the right knee is positive today. Currently, the pain in the right knee is a major issue for the patient, as it is cutting down the patient’s activity further. Patient is being scheduled an appointment shortly with an orthopedist. PT suggested by RN today. But, caregiver reports that they would want to wait until they see the orthopedist and get his suggestion. Blood pressures have been low in the last 2 months, with the patient reporting increased frequency of episodes of confusion. Caregiver reports episodes of partial disorientation. Bilateral breath sounds in the bases were diminished.

 

#3

Reason(s) for Home Health Recertification

  • Recurrent UTIs
  • Irritable Bowel Syndrome
  • Limited ROM

In the recent past, patient came down with several episodes of UTI. Patient is currently being evaluated for any blockage in the urinary tract resulting in retention of urine and consequent infections. Patient is currently seeing Dr. A for this. Patient reports the urinary incontinence has deteriorated in the recent past, with increase in the number of accidents she is having. Patient reports no history of renal stones. Patient reports episodes of GERD to be more frequent in the recent times. Patient was having irritable bowel and was on Imodium. Patient reports the bowel to have settled and she is taking Imodium sparingly. Bowel incontinence was secondary to hypermotility, which is reportedly calming down. Patient had bilateral knee joint replacements and was in rehab for about a year, before she came on to home health service. Her ROM with her knees was an issue initially, making her at risk for fall. She had a number of falls before, but none in the last 2 months. This situation has gradually improved with providing therapy at home in the last 2 months. The weakness and balance issues still continue, but better than 2 months ago. Therapy has discharged her, as she met the functional goals. Patient was provided with the HEP. Patient reports compliance with practicing the HEP sessions, as instructed upon by therapist. Patient has to be closely followed-up on her compliance with activity recommended. No active wounds currently on the patient.