M & M HOME CARE: NURSE VISIT

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NURSING VISIT PROGRESS NOTE
PATIENT NAME PATIENT NAME First Last
PATIENT DOB: PATIENT DOB: / MM / DD YYYY
VISIT DATE: VISIT DATE: / MM / DD YYYY
VISIT STARTED VISIT STARTED : HH MM
VISIT ENDED VISIT ENDED : HH MM
VITAL SIGNS
B/P
PULSE
RESPIRATION
TEMPERATURE
SpO2
GLUCOSE
WEIGHT
PAIN
INTENSITY OF PAIN
FREQUENCY OF PAIN

FREQUENCY OF PAIN 0 - HAS NO PAIN 1 - HAS PAIN THAT DOES NOT INTERFER WITH ACTIVITY OR MOVEMENT 2 - LESS OFTEN THAN DAILY 3 - DAILY BUT NOT CONSTANT 4 - ALL OF THE TIME
PAIN SITE(S)
PAIN DESCRIPTION
Shooting Sharp Hot Radiating Numb Tingling Deep Aching Heavy Dull Cramping Throbbing Other Other
ALLEVIATING FACTORS
Medications Massage Heat Cold Changing position Being active Resting Other Other
AGGRAVATING FACTORS
Movement Positonal Lying down Walking Standing Other Other
COMMENTS
CARDIOVASCULAR
NO CARDIOVASCULAR DEFICIT
Chest pain/angina Tachycardia Palpitations Bradycardia SOB / Dyspnea JVD Orthopnea Poor Capillary Refill Syncope / Fainting Other Other
PERIPHERAL PULSES

PERIPHERAL PULSES Present Absent Faint
EDEMA PRESENT?

EDEMA PRESENT? Yes No
Non-Pitting Edema Pitting Edema +1 +2 +3 +4 Location Location
COMMENTS
RESPIRATORY
NO RESPIRATORY DEFICIT
CLEAR TO AUSCULTATION BILAT.
SOB / Dyspnea Hemoptysis Rales Ronchi Wheezing Other Other
COUGH

COUGH Productive Non-Productive
VENT / OXYGEN PRESENT?

VENT / OXYGEN PRESENT? YES NO
OXYGEN DELIVERY DEVICE
RATE
VOLUME
FiO2
PEEP
O2 at (l/min)
COMMENTS
NEUROLOGICAL
NO NEUROLOGICAL DEFICIT
ORIENTATION:

ORIENTATION: Person Place Time Situation
Seizures Present Comatose Tremors Lethargic Forgetful Other Other
PUPILLARY RESPONSE:

PUPILLARY RESPONSE: Equal Reactive Dilated Pin Point Sluggish Unreactive
COMMENTS
MUSCULOSKELETAL
NO MUSCULOSKELETAL DEFICIT
Pain Present Limited ROM Weakness Paralysis Decreased Endurance Contractures Unsteady Gait Spasms Unequal Grip Strength Use of Assistive Devices Other Other
COMMENTS
ASSISTIVE DEVICES
NO ASSISTIVE DEVICES PRESENT
ASSISTIVE DEVICES

ASSISTIVE DEVICES Wheelchair Walker Scooters Canes Crutches Prosthetic devices Orthotic devices Other Other
COMMENTS
GENITOURINARY
NO GENITOURINARY DEFICIT
Distention Retention Burning Pain with Voiding Hematuria Oliguria Increased Frequency Intermittent Straight Cath. Other Other
CATHETERS

CATHETERS Foley Cath Present Suprapubic Cath Present Urine Clear Large Drainage Bag SP Dressing Dry & Intact Urine Cloudy / Sediment Noted Leg Bag Present Insertion Site Clean & Dry Urine Bloody To Dependent Drainage Insertion Site Reddened Encouraged Increased Fluids to Flush System
Catheter Size (Fr.)
Residual Present (ml)
COMMENTS
GI / DIGESTIVE
NO GI DEFICIT
LAST REPORTED BOWEL MOVEMENT LAST REPORTED BOWEL MOVEMENT / MM / DD YYYY
NPO Diarrhea / Loose Stool Nausea Vomiting Bowel Sounds Absent Other Other
NGT / PEG Present Placement Checked PEG Dressing Dry & Intact PEG Site Clear PEG Site Reddened
COMMENTS
SKIN / INTEGUMENTARY
NO INTEGUMENTARY DEFICIT
Warm Dry Bruising Diaphoretic Cool Clammy Pale Flushed Other Other
Wound Present Wound Assessment Completed
COMMENTS
ENDOCRINE
NO ENDOCRINE DEFICIT
Glucometer Readings Insulin Dependent Other Other
COMMENTS
MENTAL HEALTH
NO MENTAL HEALTH DEFICIT
Inappropriate Behavior Depressed Crying Agitated Other Other
COMMENTS
MEDICATIONS
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15 (IF ADDITIONAL MEDICATIONS ARE PRESENT - SELECT "OTHER" AND LIST MEDS)
OTHER MEDICATIONS
OTC MEDS / SUPPLEMENTS
MEDICATION LIST REVIEWED NOT APPLICABLE
No Changes Noted
MEDICATION CHANGES
ADLs / IADLs


	FULL ASSIST	PARTIAL ASSIST	STANDY BY ASSIST	INDEPENDENT	N/A
Toileting	ToiletingFULL ASSIST	ToiletingPARTIAL ASSIST	ToiletingSTANDY BY ASSIST	ToiletingINDEPENDENT	ToiletingN/A
Dressing	DressingFULL ASSIST	DressingPARTIAL ASSIST	DressingSTANDY BY ASSIST	DressingINDEPENDENT	DressingN/A
Ambulation	AmbulationFULL ASSIST	AmbulationPARTIAL ASSIST	AmbulationSTANDY BY ASSIST	AmbulationINDEPENDENT	AmbulationN/A
Feeding	FeedingFULL ASSIST	FeedingPARTIAL ASSIST	FeedingSTANDY BY ASSIST	FeedingINDEPENDENT	FeedingN/A
Grooming	GroomingFULL ASSIST	GroomingPARTIAL ASSIST	GroomingSTANDY BY ASSIST	GroomingINDEPENDENT	GroomingN/A
Bathing	BathingFULL ASSIST	BathingPARTIAL ASSIST	BathingSTANDY BY ASSIST	BathingINDEPENDENT	BathingN/A
Bed mobility	Bed mobilityFULL ASSIST	Bed mobilityPARTIAL ASSIST	Bed mobilitySTANDY BY ASSIST	Bed mobilityINDEPENDENT	Bed mobilityN/A
Functional transfers	Functional transfersFULL ASSIST	Functional transfersPARTIAL ASSIST	Functional transfersSTANDY BY ASSIST	Functional transfersINDEPENDENT	Functional transfersN/A
Community mobility	Community mobilityFULL ASSIST	Community mobilityPARTIAL ASSIST	Community mobilitySTANDY BY ASSIST	Community mobilityINDEPENDENT	Community mobilityN/A
Medication management	Medication managementFULL ASSIST	Medication managementPARTIAL ASSIST	Medication managementSTANDY BY ASSIST	Medication managementINDEPENDENT	Medication managementN/A
Laundry tasks	Laundry tasksFULL ASSIST	Laundry tasksPARTIAL ASSIST	Laundry tasksSTANDY BY ASSIST	Laundry tasksINDEPENDENT	Laundry tasksN/A
Ability to Use The Telephone	Ability to Use The TelephoneFULL ASSIST	Ability to Use The TelephonePARTIAL ASSIST	Ability to Use The TelephoneSTANDY BY ASSIST	Ability to Use The TelephoneINDEPENDENT	Ability to Use The TelephoneN/A
Food Preparation	Food PreparationFULL ASSIST	Food PreparationPARTIAL ASSIST	Food PreparationSTANDY BY ASSIST	Food PreparationINDEPENDENT	Food PreparationN/A
Housekeeping	HousekeepingFULL ASSIST	HousekeepingPARTIAL ASSIST	HousekeepingSTANDY BY ASSIST	HousekeepingINDEPENDENT	HousekeepingN/A
Ability to Handle Finances	Ability to Handle FinancesFULL ASSIST	Ability to Handle FinancesPARTIAL ASSIST	Ability to Handle FinancesSTANDY BY ASSIST	Ability to Handle FinancesINDEPENDENT	Ability to Handle FinancesN/A

Full Assistance - If the care giver does ALL of the effort. Patient does none of the effort to complete the activity, OR the assistance of two or more care givers is required to complete the activity.

Partial Assistance - If the care giver does LESS THAN HALF the effort. Care giver lifts, holds, or supports trunk or limbs, but provides less than half the effort.

Stand By Assistance - If the caregiver provides VERBAL CUES or TOUCHING/STEADYING assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently

Independent - If the Patient completes the activity by him/herself with no assistance from a caregiver.
TREATMENT(S) PERFORMED
INTERVENTIONS
Vital Sign Interventions Pain Interventions Respiratory Interventions Muscoskeletal Interventions Cardiovascular Interventions Neurologial Interventions GU Interventions GI Interventions Integumentary Interventions Mental Health Intervientions
Patient tolerated interventions well Patient did not tolerate interventions
PATIENT RESPONSE TO TEACHING
Patient / CG verbalized/demonstrated understanding of instructions provided Patient / CG unable to verbalize/demonstrate understanding of instructions provided
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PLAN FOR NEXT VISIT
Patient to be discharged Continued assessment / care Other Other

M & M HOME CARE: NURSE VISIT

NURSING VISIT PROGRESS NOTE

VITAL SIGNS

PAIN

PAIN DESCRIPTION

ALLEVIATING FACTORS

AGGRAVATING FACTORS

CARDIOVASCULAR

RESPIRATORY

NEUROLOGICAL

MUSCULOSKELETAL

ASSISTIVE DEVICES

GENITOURINARY

GI / DIGESTIVE

SKIN / INTEGUMENTARY

ENDOCRINE

MENTAL HEALTH

MEDICATIONS

ADLs / IADLs

TREATMENT(S) PERFORMED

INTERVENTIONS

PATIENT RESPONSE TO TEACHING

PLAN FOR NEXT VISIT