Home Health Skilled Nursing Documentation Example

This post provides skilled nursing documentation example for writing assessment note for Resumption of Care and Start of Care in home healthcare setting. We have listed the reasons for patient’s hospitalization. Based on those reasons, we have built a summary which can explain and justify the need for resumption of care for home healthcare patient services.

Home Health Skilled Nursing Documentation Example – Resumption of Care

Example 1

Reason(s) for Hospitalization

  • 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, English speaking, 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 the customer care representative YYY regarding the refill. YYY 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.

Example 2

Reason(s) for Hospitalization

  • Rectal Prolapse Surgery

Patient is an 80-year-old female who was admitted to XXX for rectal prolapse and patient had surgery on 04/12/2012. She was there until 04/18/2012 and then, went to YYY Rehab on 04/19/2012 and came out on 04/29/2012. Patient is very debilitated currently with weakness and markedly limited endurance. Patient’s other health history includes HTN, DM2, aortic valve regurgitation, congestive heart failure, hypothyroidism, seizures, hypercholesterolemia, GERD, and anemia, and osteoarthritis. Patient’s surgical history includes 2 colon resections secondary to diverticulosis and a hysterectomy and bilateral oophorectomy. Patient also has family history of cancer and one sibling died of breast cancer with metastases to bone. Other significant health history includes significant risk for fall with the caregiver reporting a serious fall in May 2009 and sustaining a head injury and resulting concussion. The patient also had another fall in September 2010, but without any injuries.

Example 3

Reason(s) for Hospitalization

  • Stroke

Patient went in into the hospital on 05/20/2011 for a stroke. Patient was taken to ER at XXX. No after effects of stroke were noted currently. No deviation of angle of mouth noted. Motor strength is very weak though in both upper arms. No signs of any gross hemiplegia noted currently. Patient’s passive ROM in both upper extremities appear to be WNL. Phantom limb pain complained in the RLE stump. Patient came out of XXX on 06/06/2011.

 

Home Health Skilled Nursing Documentation Example – Start of Care

We have listed the reasons for patient’s admission assessment and based on those reasons we have built a summary which will explain and justify the need for admitting the patient to home healthcare services.

Example 4

Reason(s) for Home Health Admission

  • Colon Cancer
  • Colostomy

Patient is a 72-year-old male patient who lives with his spouse. Patient is alert and oriented x 3. Patient was diagnosed with colon cancer. No family history of cancer. Patient started having chemo in February 2011. Next session of chemo is on 04/23/2011. Patient does not report any bothersome nausea and vomiting for now. Patient is not independent with ostomy care and caregiver sounded unwilling to help with ostomy care. Nursing services are needed twice a week for colostomy bag change. The plan is to reconnect the bowel back next month. Patient probably is losing fluid secondary to the ostomy. Patient’s skin turgor was noted to be poor with mild tenting of skin.

 

Example 5

Reason(s) for Home Health Admission

  • Parkinson’s Disease
  • Fall

Patient is a 75-year-old pleasant woman with history of Parkinson’s disease with markedly limited ROM, osteoarthritis involving low back and bilateral hips. Caregiver reports patient having a fall in December 2011 and she is at significant risk for fall. Patient for the most part is limited to her wheelchair needing maximum assistance to assume a standing posture. She has a stooped posture on standing. Her rigidity secondary to Parkinson’s limits her mobility and ROM. Has mild resting tremor in the fingers. Patient has mild difficulty initiating a movement. Motor strength all over noted to be weak.

Example 6

Reason(s) for Home Health Admission

  • Osteomyelitis
  • Amputation
  • Cellulitis
  • Panniculitis
  • Recently Turned Diabetes

 

In 2005, patient had a car wreck and his right tibia got infected (osteomyelitis) and 3 inches of the bone was removed in 2005 during the hospitalization, post-accident. The infection in the bone became chronic with repeated MRSA infections and bacteremia and finally, right BKA had to be performed in 2009. Since then, patient has episodes of repeated cellulitis and panniculitis. Current episode started on 02/26/2011with the patient demonstrating constitutional symptoms of infection. Patient was taken to ER at XXX. Patient had multiple weeping sites on the abdominal skin. They are under control currently. Patient was stabilized. Cultures were performed on the patient and patient was later admitted to the floor with antibiotics. Patient was later taken to YYY rehab. Initially, he was managed on IV antibiotics and then, oral. The patient does not recall IV antibiotics he was on. The oral antibiotics are still continuing. Patient is currently on Minocycline 100 mg twice daily. Patient came out of YYY Rehab yesterday. The skin on the abdomen has some erythematous spots that probably were the drainage sites, when the infection was active. Patient is being considered for panniculectomy shortly, probably next week. Patient’s past surgical history includes a gastric bypass. Patient reports he turned diabetic recently. Patient reports that his HbA1c was not that elevated. He is currently started on Novolog insulin. Patient needs help with getting this filled. A social worker is seeing him shortly to facilitate his insulin getting filled. Patient reports that after having his surgery (panniculectomy) and removal of tissue, he was told that he might not be a diabetic and might not need insulin. RN currently is not aware of the dosage on the insulin. Patient reports continence with bowel and bladder. As he is mostly bedbound, he uses a urinal, bedside commode, and bedpan. Patient is dependent on ADL and IADL performance and caregiver needs assistance. Patient wanted the HHA to start coming next week.

 

You can generate admission assessment summary similar to home health skilled nursing documentation example in this post using our customizable OASIS templates. Our OASIS templates generate customized narratives for individual patient needs with few clicks. The narrative is generated once you click the Submit button at the end of the page. This  summary could be copied and pasted into the comments section, if you use an EMR software, or copied and pasted onto an addendum sheet that you can attach to the OASIS form if you use paper documentation. This helps in making the nursing visit note documentation quicker and easier.

We offer customizable skilled nursing documentation templates for Start of Care, Resumption of Care, Recertification Evaluation, 60-Day Summary and Discharge.

 

We have provided a demo OASIS assessment template where you can generate discharge summary using selection options provided. Please visit OASIS Discharge Template

 

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