OASIS Assessment Narrative Templates

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#1

Reason(s) for Home Health Recertification

  • Diminishing Response to Neuro- Emotional Status
  • Increasing Frequency of Urinary Incontinence

Patient appeared very passive, calm, and hardly responsive. He appeared a little confused with regards to orientation of his room, while walking back in from the restroom. Episodes of confusion on and off. Patient also has a history of seizures. No seizures reported in recent times, as caregiver observes. But, caregiver is not sure, as the patient sometimes looks blanked out and caregiver is quite not sure, if he is having a seizure during this time. No motor activity of seizure was noted though. No injuries reported. Patient had 2 falls though during the last 2 months and they were uneventful. Patient was aware and oriented when he fell both times. Patient had physical therapy and occupational therapy in the last 2 months. Patient is not being compliant with the HEP established by the therapist. Skin turgor appeared fair. Caregiver reports increase in the frequency of urinary incontinence in recent times. Patient will wet himself and sometimes needs to be told to clean and change himself up. Patient appeared very slow and sluggish with regards to activity. Caregiver reports the patient’s appetite to be doing within reasonable limits. Patient denied to weigh today and said he wants to rest. RN tried asking him, if there is something bothering him. But, patient hardly answered. No risk for skin integrity was noted currently. Skin on the dependent portions of the body was noted to be intact, but very dry.

 

#2

Reason(s) for Home Health Recertification

  • Worsening Heart Failure with Un-resolving Edema and Fluid Retention
  • Increasing SOB
  • Weight Gain Due to Fluid Retention

Pain in the knee joints varies between 2 – 7. Pain mostly stays at 3 or 4, with occasional exacerbation to 6 or 7. Patient also reports some gouty arthritis pains in the small joints of hands, precipitated with change of environment. Heart sounds were regular. Patient is a known case of CHF. Pedal edema has been a consistent finding throughout the certification period. Pedal edema for the most part in the certification period was at 2+ or 3+. Patient’s weight over the certification period varied between 211.6 and 225. But, there is no weight gain over 5 lbs. in a week, through the certification period. Patient also presented with increasing SOB and compromised endurance in recent times. Over the certification period systolic blood pressure varied between 95 and 155 and diastolic blood pressure varied between 60 and 90. Pulse varied between 60 and 76. Patient also reported some episodes of dizziness, probably secondary to low pressures. Patient reports burning sensation in the urethra for the last 24 hours. Patient called his doctor’s office today to report the findings. Patient was instructed to drink cranberry juice for now and they will reach out to him in a little while again. Patient reports frequenting for urination. But, he is not sure if the frequency is secondary to the UTI or prostate issues, as frequency has been an issue always. Patient reported mild foul odor to the urine, as well. Temperature WNL. No chills and rigors reported. Patient needs continued home health services for SN instructions regarding UTI prevention, CHF management, dietary compliance, management of BPH and urinary retention.

#3

Reason(s) for Home Health Recertification

  • Diminishing Renal function and CKD
  • Diminishing Appetite and Skin Turgor
  • Current Episode of UTI and BPH
  • Uncontrolled Blood Pressure

Patient is currently appearing weak with diminished ability for ambulation. But, he is appearing better compared to the last assessment visit. Patient’s intake has reportedly decreased for some time. So, patient was started on Nepro 240 m1 1 can twice daily. Patient has improved after that. Caregiver reports that the patient eats at least one good meal a day currently. But, he lost about 7 pounds in the last one and half month, as caregiver reports. Patient’s skin turgor appears poor and the skin was dry. No gross tenting of skin was noted though. Patient is currently having a bladder infection for the last one week and is having polyuria, probably resulting in dehydration. Caregiver was instructed that skin turgor is a major factor for preventing risk for skin integrity. So, caregiver was instructed upon having the patient drink the daily requirement of fluid every day. No maximum daily fluid allowance has been recommended in the wake of diminishing renal function yet, as caregiver reports. Heart sounds regular. BP readings are being out of place in recent times. Caregiver reports diminishing kidney function and fluid retention by the patient. Patient is being closely watched. The high blood pressure readings could be secondary to fluid retention, due to diminishing renal function. Recurrent UTI is the major issue currently. History of CKD is +ve. History of BPH with urinary retention adds to the constellation of urinary problems. Patient is currently on Tamsulosin for BPH. History of TURP is +ve.