Progress Note Draft Template (Page 3 of 4) in pdf

___________________________________________________________________________________________________________________________________________

Other:

Objective:

Vital Signs:

T=________

P=_________

R=__________ BP=_______/_______ Height=__________Weight=_______________

General Appearance___________________________________________________________________________________________

Objective Findings: ___________________________________________________________________________________________

_________________________________________________________________________________________________

Assessment:

__________________________________________________________________________________________________

_________________________________________________________________________________________________

Plan/Orders:

__________________________________________________________________________________________________

Plan for Home Health Services:



This patient requires Skilled Nursing Services:

pecify services needed

_________________________________________________________________________________________________

__________________________________________________________________________________________________

This patient needs to be evaluated and treated for one or more of the following services

(Check all that apply.)

 Physical Therapy (specify services needed) ______________________________________________________________________

____________________________________________________________________________________________________________

 Occupational Therapy: (specify services needed) __________________________________________________________________

____________________________________________________________________________________________________________

 Speech Language Pathology: (specify services needed)

____________________________________________________________________________________________________________

To receive home health services, the patient must be homebound and meet Medicare’s criteria for “Confined

to the Home.”

 Check here and continue if choosing to document homebound status as part of this Progress Note.

[In the e-clinical template, the “Homebound Status” section will not appear if not checked.]

Homebound Status:

Medicare considers the patient homebound if the ONE of criteria A and BOTH of criteria B are met:

Criteria A: Select and describe at least one.



Because of illness or injury, the patient needs the aid of supportive devices such as crutches, canes, wheelchairs, and

walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence.

Specify: ____________________________________________________________________________________________

Progress Note Draft Template Page 3