Nursing Assessment Documentation Templates

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#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 – 98 over the last certification period. Pulse varied between 55 – 97. Patient’s systolic blood pressure on caregiver readings was as high as 187. Patient was discontinued on Atenolol on 04/08/2011. Patient was started on Diovan recently, on 05/03/2011. The blood pressures have not settled yet completely. Urinary and bowel incontinence sometimes happen, but manageable. Caregiver reports that she encourages the patient for a timed voiding pattern. But, due to the drowsiness and sleepy state of patient for significant part of day, timed voiding cannot happen, thereby precipitating accidents. Patient mostly displays a flat affect and caregiver responds most of the time. No psychosocial issues identified or reported. Patient stayed partially oriented for the most part of the certification period with altered level of consciousness. Patient is not very compliant with the HEP established by the therapist. Caregiver reports that she will try to encourage the patient for it, but he would sleep for most part and does not participate. Patient saw his PCP Dr. A, once during this certification period, for follow-up on his blood pressure. No other doctor visits happened in recent times. Patient had no falls in recent times. No infections reported in recent times. Patient is being recertified for continued home health services, as the patient’s blood pressure are unsteady. SN visits are needed to follow closely on the blood pressure readings, in the wake of new anti-HTN medication. HHA services to assist with ADL/IADL performance.

 

#2

Reason(s) for Home Health Recertification

  • Deteriorating Ventricular Function and Heart Failure
  • One Hospitalization Due to Fluid Back Up in Lungs and Exacerbation of SOB
  • One More Hospitalization Due to UTI and Pyelonephritis

Dr. A, from XXX is his new home visit doctor. Dr. A saw him on 12/02/2009. Patient had a flu shot from him. Patient also had an ECG and blood work done by Dr. A. ECG showed some exacerbation of ventricular functional defect. Chest X-ray and sonogram have been ordered for follow-up. Patient is having them today, for follow-up on his CHF. Dr. A will be seeing him once every month henceforth. Patient had the left hip partial replacement, performed by Dr. B at YYY, during this certification period and was in rehab after his surgery. Pain is not a major issue for the patient. Currently, spasms limiting his ROM around the surgical hip joint is something that bothers him. PT is continuing. Crepitations in bilateral lower lobes, both anteriorly and posteriorly on the lungs are heard. But, they sound better and have improved in intensity compared to the previous assessment visit on the patient. This could be an evidence of backing up of fluid in his lungs, secondary to his CHF status. Caregiver reports the patient’s endurance and activity to have improved slightly, secondary to the therapy, but the spasms in his left hip joint are still continuing to limit activity. Pedal edema is being noted more frequently in recent times. Peripheral pulses in BLE difficult to appreciate. Patient is a known case of benign prostatic hypertrophy and is on Tamsulosin for the same. Caregiver reports the patient wears depends. Some stress incontinence is reported. Caregiver was instructed upon not giving the patient his diuretic during the night, as this can cause frequency and urgency during the night and consequently risk for more episodes of incontinence. Patient had one episode of UTI and pyelonephritis recently. Caregiver reports the patient to have bowel movements regularly and constipation is not a major issue. Once in a while, he needs an OTC laxative, but mostly he is good on that. Caregiver reports some episodes of GERD to be occurring.

#3

Reason(s) for Home Health Recertification

  • Fall and One Episode of Hospitalization
  • Compromised Coronary Circulation with No Episodes of Chest Pain
  • Deteriorating Atrial Fibrillation
  • Urinary Incontinence

Patient is alert and oriented x 3 today during the period of assessment. Patient had one fall and hospitalization during the certification period 07/08/2012 – 09/06/2012, secondary to dehydration. Pain status deteriorated in recent times with the patient started back on Norco for management. Patient has a poor balance and with the diffuse joint pains and ambulation difficulty she has, patient is mostly limited to her scooter for the most part. Therapy was indicated, but the patient denied it for now. SN to follow up on it during the episode of care. Patient has very poor vision, secondary to macular degeneration. Patient needs help with insulin administration every morning (Monday through Friday) during to caregiver unavailability. Patient saw her PCP, Dr. A, on 08/16/2012. Patient was started on Isosorbide Mononitrate 30 mg ER 1 tab qd, as compromised blood supply was suspected to the myocardium on evaluation. Patient will see her PCP again in September for follow-up. No visits in recent times to Dr. B. Also, patient’s atrial fibrillation has been acting up in recent times. Patient has been started on Amiodarone 200 mg in July by her Cardiologist Dr. C. Patient saw him last on 08/16/2012. Patient is seeing Dr. C back on 12/21/2012. Patient did not have any visits with her urologist Dr. D in recent times. Next appointment is on 12/11/2012. Urinary incontinence and bowel incontinence continue. Patient will see her vascular surgeon, Dr. E on 10/16/2012.