Skilled Nursing Visit Record Template

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TRUE CARE PROFESSIONALS FLA, LLC.
Skilled Nursing Visit Record
Patient’s Name
______________________________________________ ID #_________________________
Date______________
Time in_______________ AM / PM
Time out______________ AM / PM
STATUS:
# of times patient leaves home? week________ How long was patient away?__________ Assistive device used _______________
Regular Visit
PRN Visit Other
Did patient leave home?
YES
ther___________
NO
MD appt
Adult day care
O
SKILLED SERVICE PROVIDED
Medication Assessment
Teach Medication schedule
Assess Medication Knowledge
Medications taught
Skilled Observation
Teach adm of injection
Adm. Of
1)____________________
Foley Insertion#__FR__mL
Teach cath care
Intramuscular-subq
2)____________________
Safety Assess
balloon
Teach Safety
Adm. Of Vit. B12
3)____________________
Adm. Of IV
Teach IV site care
Teach eye care
Assess pain
Wound Care-Dressing
Teach Wound Care
Prep-Adm of Insulin
Teach pain management
Assess stoma
Teach Ostomy
Teach Diabetic care
Teach Disease Process
Ileal Conduit Care
Teach Parenteral Nutrition
Decubitus Care
Discuss discharge plan
Bowel-Bladder Training
Teach Tube Feedings
Assess cardiopulmonary status
Evaluation
Disimpaction-enema
Teach Bowel Care
Assess neuro status
Management-Evaluation
Assess nutritional status
Teach Nutrition
Assess musculoskeletal
Plan of Care
Adm. Inhalation Tx
Teach Inhalation Tx
Assess GI-GU
Discuss POC
Adm. Care of Trach
Teach care of Trach
Chest Physio
Other:________________
IV checked for free
(inc. Postural Drainage)
Alarms can be heard
flow protection
Alarm checked
HHA Introduction
Y
N
Pt. Satisfied with Care
Y
N
Document HHA teaching ___
HHA Supervision
Y
in section 5
N
POC Updated-Reviewed
Y
N
HHA Teaching*
Y
N
Visits frequency:
Increase
Decrease
Discontinued
No change
SKILLED OBSERVATIONS-EVALUATION
Edema Y
N
WT ______ Last BM______ CBS_______
Pain:
0 1 2 3 4 5 6 7 8 9 10 Labs Done:
Type____________________________________________
Self Assessment
Temp: _________
BP
Rt
Lt
LE measurements (cm) Wound One (cm)___ Wound Two (cm)______
AP: ___________
Lying______ ______ Rt Calf_______ L Calf_________ Length___________ ______________
RP: ___________
Sitting______ ______ Ankle_________ Ankle _______ Width ___________
______________
Resp: __________
Stand______ _______ Instep________ Instep ________
Depth ___________
_____________
Lung Sounds _____________________________________________________
Drng amt _______
_______________
Abd Girth ________________________ in ___________________________
Drng amt _______
_______________
OBSERVATIONS-ASSESSMENT-CARE (Record signs, symptoms, changes in patient’s condition since last visit)
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Other 
TEACHING PROVIDED to: Patient
Family member
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
RESPONSE TO TEACHING
Good
Fair
Poor
Anxious
Cannot cope
Verbal / Understand
Y
N
Needs further supervision in:_____________________________
Returns demonstration correctly
Y
N
Needs further instruction in:_____________________________
Problem-teaching resolved for:____________________
PLAN FOR NEXT VISIT (Include any modification in care plan)_________________________________________________
_________________________________________________________________________________________________________
Physician Call: Y
N
Memo Sent
Case conference: Y
N
Next MD Appt_____________________
Remarks / Note____________________________________________________________________________________________
_________________________________________________________________________________________________________
Signature_________________________________________Title__________________ Date:___________

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