OASIS Template Sample - Home Health Patient Education

Is patient borderline hypertensive/hypertensive?

Yes
No

Borderline Hypertension

Patient is a borderline hypertensive.
Patient is not on any medications currently.
Blood pressures are being closely watched.

Hypertension

Patient is a chronic hypertensive and is on medications for management.
Patient is recently diagnosed with hypertension.
Patient is not on any medications currently.
Patient progressed from borderline hypertension to hypertension in recent times.
Patient was started on antihypertensive medication recently for BP control.

Current Antihypertensive Medications (name only)

Blood pressure control recently

Recent changes with antihypertensive medications

no changes happened with antihypertensive medications
dose changes happened with antihypertensive medications
new antihypertensive medications are added

Stroke and Hospitalization

Patient has history of an episode of stroke, secondary to poorly managed HTN.
Patient had one episode of suspected stroke recently, but was ruled out on evaluation.
Patient had one episode of stroke recently, secondary to poorly managed HTN.
Patient underwent an ER visit and hospitalization following the stroke.

Compliance with antihypertensive medications

compliance
partial compliance
noncompliance

Compliance with daily blood pressure reading and log maintenance

compliance
partial compliance
noncompliance

Does patient complain of any hypotensive episodes?

Yes
No

Hypotensive Episodes

Patient’s blood pressure readings are being on the lower side in recent times.
Patient has history of orthostatic hypotension and reports episodes of dizziness and confusion with sudden change in position.
Patient reports on and off episodes of dizziness, secondary to low blood pressure numbers.
Blood pressure readings are being closely watched.

Medication changes lately for management of hypotensive episodes

Patient was discontinued on antihypertensive medications lately, for better control of blood pressure readings.
Dose of antihypertensive medication was reduced lately, for better control of hypotensive symptoms.
Patient’s dose of diuretics was decreased in recent times, for better management of hypotensive episodes.

Limitations Regarding Site of BP Recording

Patient’s BP to be taken on right arm, secondary to history of mastectomy/lymph node removal on the left.
Patient’s BP to be taken on left arm, secondary to history of mastectomy/lymph node removal on the right.

Was blood pressure elevated during the visit today?

Yes
No

Elevated Blood Pressure During the Visit

Blood pressure reading was elevated today, during the time of SN visit.
Noncompliance with dietary recommendations contribute to elevated BP numbers.
Patient forgot taking dose of antihypertensive medications.
RN administered antihypertensive medication today during the visit.
Patient reports having taken the medication, just a while ago.
Blood pressure was noted to be stable, 30 minutes after taking the medication, when RN left.
Patient’s elevated blood pressure numbers were reported to the physician.
Caregiver was available for follow-up.

Normal Heart Rate

No issues reported with patient’s heart rate.
Heart rate was reported to be in normal limits in recent times.

Altered Heart Rate

Patient has chronic history of tachycardia and is on medication for management of the same.
Patient was recently diagnosed with tachycardia and was started on medication for management of the same.
Patient reports elevated heart rate lately, probably as a compensation to the low BP numbers in recent times.
Patient’s heart rate usually is on the lower side, secondary to good vagal tone.
Patient has chronic history of bradycardia.
Patient has been presenting with episodes of bradycardia and dizziness lately.
Patient’s blood pressure and heart rate are currently being closely monitored.

Does patient have history of CHF?

Yes
No

Congestive Heart Failure

Patient has history of chronic CHF and is on medications for management.
Patient was recently diagnosed with CHF, with medication changes for managing the same.

CHF management

decently managed
mild to moderately managed
poorly managed

Symptoms of CHF

dizziness ;
headache ;
increased frequency and exacerbation of episodes of SOB ;
compromised endurance ;
fluid retention ;

Other CHF symptoms

Pedal Edema and Fluid Retention in Recent Times

Patient reports no episodes of pedal edema in recent times.
Patient reports on and off episodes of pedal edema in recent times.
Patient reports that pedal edema has been more consistent finding in recent times.
Patient reports low – moderate grade edema to be consistent finding in recent times.
Intensity of edema and fluid retention have progressively increased in recent times, as patient reports.
Deterioration of edema status was reported to the physician.

Pedal Edema during the Visit Today (number only)

Exacerbation Factors for Pedal Edema

poor compliance with recommendations on heart healthy diet ;
noncompliance with dialysis schedule ;
exacerbation of heart failure ;
Exacerbation of COPD in recent times ;

Other exacerbation factors for pedal edema

Fluid Volume Limitations in liter (number only)

Knowledge regarding fluid volume limitations

knowledgable
poorly knowledgable

Compliance regarding fluid volume limitations

compliance
moderate compliance
poor compliance

Is patient taking any medications for CHF?

Yes
No

Diuretic Medication Changes for CHF

No change in the dose and frequency of diuretic happened in recent times.
Patient was started on new diuretic medication lately, for management of symptoms of CHF exacerbation.
Patient’s dose of diuretics was increased in recent times, for better management of fluid retention, secondary to CHF.
Patient’s dose of diuretics was decreased in recent times, for better management of hypotensive episodes, secondary to CHF.

Potassium Supplementation

Patient has history of hypokalemia, secondary to Lasix intake and so, is on potassium supplement, to prevent any cardiac abnormalities.
Patient was diagnosed with hypokalemia in recent times, secondary to Lasix intake and so, was started on potassium supplementation.
No changes were made with the dose of potassium supplement lately.
Changes with regards to dose of potassium supplement happened lately.
Patient is being closely monitored for the effects of potassium on cardiac function.

Recent changes with cardiac medications

no changes happened with cardiac medications
dose changes happened with cardiac medications
new cardiac medication are added

Weight Changes in Recent Times

Patient could not be weighed today, due to patient’s poor balance and high fall risk.
Patient could not be weighed today, due to patient’s bedbound status.
Weight recordings in recent times were stable, with no gross changes, as patient reports.

Abrupt Weight Gain in lb (number only)

Does patient have history of arrhythmia?

Yes
No

Normal Cardiac Rhythm

Patient has no history of cardiac arrhythmias.
Heart beat was noted to be regular at normal rate.

History of arrhythmia

Patient has chronic history of arrhythmia.
Patient was recently diagnosed with arrhythmia.

Type of arrhythmia

Arrhythmia Management Measures

Patient has been on antiarrhythmic medications for management of the arrhythmia.
Patient was started on antiarrhythmic medications, in recent times, for management of the arrhythmia.
Patient has history of undergoing cardioversion.
Patient underwent cardioversion in recent times, to restore the cardiac rhythm.
Patient has history of pacemaker insertion

Current Arrhythmia Medications (name only)

No Exacerbation of Arrhythmia

Patient’s arrhythmia was reportedly decently controlled lately, with no exacerbation of symptoms.
Patient reports arrhythmia to be mild to moderately managed in recent times.
No episodes of chest pain and palpitations reported in recent times.
No changes with regards to antiarrhythmic medications reported in recent times.

Exacerbation of Arrhythmia

Patient reports arrhythmia to be poorly managed in recent times.
Patient reportedly presented with worsening symptoms of arrhythmia in recent times.
Patient reports increased frequency of episodes of dizziness and headache in recent times.
Patient reports increased frequency and exacerbation of episodes of SOB, in recent times.
No changes with regards to antiarrhythmic medications reported in recent times.
Changes with regards to antiarrhythmic medications happened in recent times, for better control of arrhythmia and management of symptoms.

Does patient have history of hyperlipidemia?

Yes
No

Hyperlipidemia and Elevated Cholesterol

Patient has history of hyperlipidemia and atherosclerosis.
Patient has been on antihyperlipidemic medications for management of the same.
Patient was lately diagnosed with hyperlipidemia.
Patient was started on antihyperlipidemic medications for management of the same.

No Exacerbation of Hyperlipidemia

No recent evaluation of blood cholesterol levels reported.
No recent exacerbation of blood cholesterol levels reported, with no changes in the dose of antihyperlipidemic medications.
Patient presents with moderate exercise tolerance, with no changes lately.

Exacerbation of Hyperlipidemia

Patient is a poorly managed hyperlipidemic.
Exacerbation of blood cholesterol levels reported lately.
Recent changes with the antihyperlipidemic drugs reported.
Patient reports decreased exercise tolerance in recent times.

Does patient have history of anemia?

Yes
No

Patient has

iron deficiency anemia
folate deficiency anemia
vitamin B12 deficiency anemia

Supplementation for Anemia

Patient is on supplementation for the same.
Patient is not on any supplementation.

Exacerbation of Anemia

Patient presents with poor endurance and SOB.
Patient presents with delayed capillary refill.
Patient presents with pale skin and mucous membranes.

No exacerbation of Anemia

Patient/caregiver reports no gross exacerbation of SOB and compromised endurance lately.
Patient presents with capillary refill less than 3 seconds.
Skin and mucous membranes are pink in color and healthy.

Does patient have a complaint of Peripheral Vascular Disease?

Yes
No

Capillary Refill and Peripheral Vascular Disease

Patient has history of peripheral vascular disease and poor capillary refill in BLE, secondary to chronic smoking.
Patient has history of peripheral vascular disease and poor capillary refill in BLE, secondary to poorly controlled diabetes and diabetic arteriopathy.
Patient was lately diagnosed with peripheral vascular disease, secondary to history of chronic smoking.
Patient was lately diagnosed with peripheral vascular disease, secondary to poorly controlled diabetes and diabetic arteriopathy.

Normal Findings

Peripheral pulses were palpable 2+ x 4 extremities.
Capillary refill was noted to be less than 3 seconds.
Toes appeared pink in color.
BLE were felt warm to touch.

Abnormal Findings for PVD

Peripheral pulses were hardly palpable in distal extremities
Patient presents with delayed capillary refill.
Distal extremities were felt cold to touch.
BLE are discolored with some bluish coloration to the feet.

Is patient at risk for clot formation?

Yes
No

Deep Vein Thrombosis

Patient has history of DVT.
Patient has history of pulmonary emboli.
Patient is more prone for clot formation.

Anticoagulants

Is patient independent with Lovenox administration?

Yes
No

Coumadin and Lab Draws

Patient has been on coumadin for long time.
Patient was started on coumadin, in recent times.
Regular weekly labs for INR are being drawn.
Regular weekly labs for INR are ordered.

Is patient informative regarding Coumadin precautions?

informative
poorly informative

Is patient informative regarding Coumadin diet?

informative
poorly informative

Compliance reported with Coumadin diet

compliance
partial compliance
noncompliance

Dose Changes with Coumadin

No dose changes on coumadin reportedly happened in recent times.
Multiple dose changes on coumadin reportedly happened in recent times.
Patient’s last INR reading was too low and so, the Coumadin dose was hiked.
Patient’s last INR reading was high and so, Coumadin dose was reduced.
Patient’s dose of anticoagulant was adjusted secondary to episodes of hematemesis and melena.
Patient’s dose of anticoagulant was adjusted secondary to a recent episode of clot formation.

Findings watched for on assessment today

No bruises noted currently.
Mild ecchymoses and bruises, in various stages of healing, were noted on the extremities.
Patient/caregiver reports no episodes of acute exacerbation of SOB lately.
Patient/caregiver reports to have noted no episodes of hematuria or blood in stool.
Patient/caregiver report occasional episodes of red brown urine and dark colored stool, probably secondary to internal bleed due to the anticoagulant intake.
Physician was notified on the symptoms of bleeding.

INR Reading Today (number only)

Does patient have history of valvular disease?

Yes
No

Patient is a known case of

valvular stenosis
valvular insufficiency

Correction Measures

No active measures suggested for valvular abnormality, as of now.
Patient has history of surgical correction for valvular abnormality.
Currently, patient was recommended surgical correction of valvular abnormality.
Lately, patient underwent surgical correction of the valvular abnormality.

Additional Information-Cardiovascular Status