Nursing Visit Note Templates for Start of Care (SOC)

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60 Day Summary Template


Reason(s) for Home Health Admission

  • Fall
  • Head Injury
  • Subdural Hemorrhage
  • Altered LOC
  • Not Hypertensive, but BP Not Under Control After the Fall

Patient had an accidental fall, before the SOC and had a head injury with 2 episodes of subdural hemorrhage. Heart sounds were noted to be regular. Patient is not hypertensive and all her BP readings were within normal limits throughout the certification period, except today, with the systolic at 162. BP reading was reported by RN to the physician’s office. Caregiver reports that it is a sporadic reading and usually, it is not the case. Caregiver reports some dizzy episodes though, with the patient acting confused sometimes. Patient is completely blind in the right eye. Glaucoma resulted in vision loss in right eye. Left eye also developed glaucoma recently. Patient saw her eye doctor too in September and reports that the left eye too developed glaucoma, as she was told during the visit. Patient also reports that she has some deposits in cornea. Left ear is worse and right ear is mild diminished. Patient has hearing aids. Episodes of hyperacidity with reflux is an occurrence still with the patient, as caregiver reports. Caregiver reports exacerbation of acid reflux and constipation in recent times. Motor strength is weak in BLE and with diminished vision, poses a risk for fall. Patient has a poor balance. Patient saw her PCP last in September. No changes were made at this visit on her medications.



Reason(s) for Home Health Admission

  • Alcoholic Cirrhosis
  • HTN
  • Atrial Fibrillation
  • Anemia

Patient is a 70-year-old male, who reports having had a mechanical fall in recent times (date could not be recalled). Patient hurt his right knee during the fall. No fractures suffered due to fall, as family reports. But, the right knee has been hurting since then. Patient is a diabetic and is on oral antidiabetics for control. Patient reports decent control with blood sugars. Patient has no active foot ulcers currently. Patient has history of liver and pancreatic replacement, secondary to polycystic disease. Patient is hypothyroid and is on supplementation. No evidence of goiter noted, no changes with regards to voice or appetite levels reported by the patient in recent times. Patient has history of HTN and atrial fibrillation. Patient is on Methyldopa and Coreg for relief. Patient has history of elevated cholesterol and is on multiple medications for management. Heart sounds were noted to be regular. Due to the liver and kidney transplants, patient is on 3 monthly monitoring of the transplant. Patient reports some anemia sometimes and he will have Procrit injections at that time to boost the hemoglobin levels. Procrit is given as needed. Patient has history of diverticulitis with total colectomy. Patient reports loose stools due to reduced water reabsorption, secondary to lack of colon. Patient was instructed upon fluid supplementation to prevent any hypovolemic episodes. Patient has history of polycystic kidney disease with chronic kidney disease, renal failure, and dialysis. Patient currently had a renal transplant and reports good renal function on the most recent renal function evaluation. BPH with symptoms of urinary retention, weak urine stream, and dribbling of urine at the end of act. Patient is also frequenting to the restroom three times during the night, as caregiver reports. Patient saw his renal transplant doctor Dr. A 4 months ago and will follow-up with him again in the next 2 months. Patient reports seeing none on the liver transplant. Dr. B is the PCP. Patient saw his PCP on 11/23/2011. No family history of cancers. Patient reports seeing his cardiologist Dr. C 2 months ago. No further visits scheduled.



Reason(s) for Home Health Admission

  • Repeated Migraine Episodes

Patient is a 46-year-old female with history of repeated migraine attacks. Patient had an MRI on 05/16/2011. But, no structural lesions have been identified. Patient reports pain involving the neck during these migraine episodes. No passing out reported during the episodes. Patient also reports light and reading to be a stimulus in precipitating the episodes. Patient presents with emesis as well. No falls reported in recent times. Patient reports visual effects, such as, some blurring of images during the aura phase of migraine episode. Patient was asked not to drive. Patient also complains of a feeling of pins-and-needles beginning on one side in the hand and arm and spreading to the nose-mouth area on the same side. Patient also presents with numbness and loss of position sense, as she complains. Patient does not complain of any pain currently at the time of admission. Patient is currently not on Triptans or Ergotamines.



Reason(s) for Home Health Admission

  • Exacerbation of Multiple Sclerosis
  • Diffuse Body Aches and Spasms
  • Poor Motor Coordination
  • Multiple Falls
  • Worsening Bladder and Bowel Incontinence

Patient is a 69-year-old female living in a senior living facility by herself. Patient has a past medical history of MS, OA, depression, hypothyroidism, and low vision. Dr. A is the neurologist. Patient missed her last appointment due to schedule conflicts. So, preauthorization form for Avonex was not signed. RN called the XXX specialty pharmacy at 1-xxx-xxx-xxxx at xx: xx and spoke to customer care representative ABC regarding the refill. The customer care representative ABC answered that the preauthorization was faxed to Dr. A’s office today and they are waiting to hear from the office. RN also called Dr. A’s office for follow-up on preauthorization. RN was told that they will reach out to the patient on the issue today afternoon. Patient reports diffuse spasms and shooting nerve pain in the limbs. Patient also reports pain in the left eye. Pain currently is varying between 2 – 6. Heart rate was elevated at 98 today. Patient requires assistance with administration of Avonex IM injections weekly and is unable to safely administer the shot herself due to poor fine motor control in her hands and low vision. Also, patient is forgetful with regards to use of her assistive device despite repeated instructions. Patient is at increased risk for fall. Patient also is having an exacerbation of MS, as the symptoms suggest, secondary to noncompliance with Avonex. Diffuse body aches, spasms, with left eye pain, and increased frequency of incontinence of bowel and bladder reported. So, patient is being recertified on continued home health services. Patient was instructed to practice deep breathing to prevent areas of atelectasis and lung collapse in the basal areas. No complaints of diarrhea, reflux or constipation reported. No UTIs reported in recent times. No falls reported in recent times. No hospitalizations in recent times. Patient has a very poor coordination on walking. Patient was noted to be noncompliant with walker use.