Home Health Paperwork Example

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#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. Patient to continue antibiotics for 2 weeks and reports compliance with medication intake. Patient reports that she tries to keep up with required fluid intake, but sometimes slips off on it. Patient reports that this habit of hers probably resulted in her developing the current UTI she is having. Patient reports improvement with burning and frequency, but still present. Patient presented with a temperature of 99.4 today. RN made sure the medication was in her MedMinder. Patient’s blood pressure is controlled moderately, but needs a close watch, as some systolic readings have been in high 150s and touching 160. Some rigidity of posture with limited ROM is evident. Patient’s episodes of disorientation continue, thus jeopardizing safety. Those episodes of disorientation are on and off. Mild resting tremor, due to secondary parkinsonism is +ve.

#2

Reason(s) for Home Health Recertification

  • Uncontrolled Blood Pressure with Medication Changes
  • Urinary and Bowel Incontinence
  • Motor Weakness

Diastolic pressure has been within limits defined for the most part in the last certification period. Systolic continues to be high on occasions, with the number in high 140s and 150s. Patient was discontinued on Nifedical XL and was started on Amlodipine during the last certification period. Patient’s dose on Enalapril also has changed. Patient reports compliance with medication intake. Bladder spasms and bowel incontinence continue to be issues bothering the patient. The incontinence has not deteriorated from the last assessment period, but has not improved any either. Patient is on Omeprazole for GERD. Reports stabilization of GERD. Occasional constipation still bothers her. Motor power BUE has improved over the last 2 months with the therapist intervention. BLE are still weak. Patient’s activity improved in the last 2 months with the patient being ambulatory from the state of being chairfast. Gait is still fluid with poor balance. Toes still dragging on the floor. Poor coordination of muscles of BLE with poor balance, thus making the patient more prone to fall.

#3

Reason(s) for Home Health Recertification

  • Falls
  • Exacerbation of Meniere’s Disease
  • Poor Balance
  • Low Endurance
  • SOB
  • Anemia

Patient’s problems with balance continue. Caregiver reports the patient to have had a total of 2 falls in the last 2 months. The falls were uneventful though. Patient is a known case of Meniere’s disease and had a shunt procedure for inner ear about 20 years ago. Caregiver reports Meniere’s disease could be reverting, as it is 20 years since he had the shunt for inner ear. Patient is being scheduled for an evaluation on this for an E.N.T. appointment shortly. Patient saw Dr. A, his hematologist on 05/20/2011. Procrit shots continuing every Wednesday. Hemoglobin is reportedly improving. Patient had 2 units of transfusion in the last 2 months. Patient saw his PCP, Dr. B also last week. Patient had no colonoscopy and prostate exams in the last 2 months. Patient reports pain in the right knee, as he landed on this knee when he fell on 05/20/2011. No wounds noted currently. NTG patches discontinued. Small bruise that is in a healing stage noted on the forehead. No UTIs reported in recent times. No other infections reported in the last 2 months. GERD is still an issue. Constipation is being well managed.