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Patient Information
Medical History
Vital Signs & Assessment
Wound Care
Medications
Treatment & Supplies
Visit Information
Nurse Name:
Patient Name:
Visit Date:
Time In:
Time Out:
Is the Patient on Medi-Cal?
Yes
No
Medi-Cal Card Info (used for DME supplies):
Medi-Cal Card Photo:
Patient Information
Date of Birth:
Height (cm):
Weight (kg):
Gender:
Male
Female
Race:
White
Black
Hispanic
Asian
Other
Medical History
Past Surgeries:
Yes
No
What Surgery:
Date of Surgery:
Diabetes:
Yes
No
Diabetes Mellitus: BS mg/dL:
Blood Sugar Recorded Time:
Blood Sugar Checked By:
Patient
Caregiver
Nurse
Random or Fasting:
Random
Fasting
When was last blood sugar check?
Allergies:
Yes
No Known Allergies
Add Allergy
Was Patient Discharged in the Last 14 Days?
Yes
No
Patient Discharge Date:
Hospital Name:
Hospital City:
Vaccinations
*
COVID-19
Flu
Pneumonia
Tetanus
TB
Hep C
Does patient have IV access?
Yes
No
IV Insertion Date:
IV Arm:
Left Arm
Right Arm
Advanced Directives
Do Not Resuscitate (DNR)
Living Will
Medical Power of Attorney
Full Code
Education Needed
Living Situation:
Lives Alone
Lives With
Assisted Living
Name of Assisted Living:
Physician Information
Physician First Name:
Physician Last Name:
Physician Phone Number:
Primary Caregiver/Emergency Contact
Name:
Phone:
Relationship:
Pharmacy Information
Pharmacy Name:
Location/City:
Vital Signs
BP:
HR:
RR:
O2 Sat:
Temp:
Lung Sounds:
CTA Bilaterally
Rales
Rhonchi
Wheezes
Crackles
Diminished
Absent
Stridor
Patient Short of Breath:
Yes
No
On Oxygen:
Yes
No
Oxygen at % LPM NC:
Durable Medical Equipment (DME)
DME Company:
Yes
No
DME Company Name:
DME Company Phone:
Cough
Coughing:
Yes
No
Coughing Productive:
Yes
No
Coughing Color:
Falls
Fall Incident (Last 3 Months):
Yes
No
Fall Date:
Hearing
Hearing Aids:
Yes
No
Hearing Scale (1 Lowest - 3 Highest):
Hearing Aid Side:
Left
Right
Both
Vision
Vision Scale (1 Adequate - 5 Severely Impaired):
Glasses:
Yes
No
Does the Patient Have Cataracts:
Yes
No
Cataract Surgery:
Yes
No
Cataract Surgery Date:
Dentures:
Yes
No
Mental Status
Oriented
Disoriented
Person
Time
Place
Situation
Assisted Devices:
Cane
Scooter
Walker
Wheelchair
Complete Bedrest
Up as Tolerated
Wheelchair Bound
No Need for Device to Walk
None
Requires Cane/Walker to Ambulate/Transfer Safely:
Yes
No
Bladder:
No Problem/Normal
Incontinence
Diapers
Bowel:
No Problem/Normal
Incontinence
Diapers
Constipation
Diarrhea
Colostomy
Ileostomy
Urinary Catheter:
Yes
No
Catheter Details
Type:
Inserted Date:
French Size:
Enteral Feedings:
Yes
No
Gastrostomy with Pump/Bolus:
Yes
No
Continuous:
Yes
No
Feedings:
1
2
3
4
Feedings Details
Name/Type:
Amount/Rate:
Flush Protocol:
Tube Placement:
Jejunostomy
Nasogastric
Skin Conditions
What Skin Conditions:
Is Patient on Dialysis:
Yes
No
Dialysis Type:
Hemodialysis
Peritoneal
AV Graft/Fistula & CVC Site
AV Graft/Fistula Site:
Central Venous Catheter Access Site:
Form of Peritoneal Dialysis:
CCPD
IPD
CAPD
Catheter Site Free of Infection:
Yes
No
Other Dialysis Details
Dialysis Center Name:
Dialysis Center Phone:
Dialysis Days
Day of the Week
Sun
Mon
Tue
Wed
Thu
Fri
Sat
H/D Date
Edema:
Yes
No
Pitting:
+1
+2
+3
+4
Pitting Location(s):
Left Arm
Right Arm
Left Leg
Right Leg
Wound Assessment
Wound:
Yes
No
Wound Stage:
1
2
3
4
Is There Any Tunneling:
Yes
No
Wound Size
Wound Length (cm):
Wound Width (cm):
Site:
Site:
Body Diagram (Select Regions)
Front
Back
Wound Photos (up to 20):
Add Wound Photo
Medication List (up to 20)
Medication 1
Input Method:
Text Details
Photo Only
Name:
Dosage:
Frequency:
Photo:
Medication 2
Input Method:
Text Details
Photo Only
Name:
Dosage:
Frequency:
Photo:
Medication 3
Input Method:
Text Details
Photo Only
Name:
Dosage:
Frequency:
Photo:
Medication 4
Name:
Dosage:
Frequency:
Photo:
Medication 5
Name:
Dosage:
Frequency:
Photo:
Medication 6
Name:
Dosage:
Frequency:
Photo:
Medication 7
Name:
Dosage:
Frequency:
Photo:
Medication 8
Name:
Dosage:
Frequency:
Photo:
Medication 9
Name:
Dosage:
Frequency:
Photo:
Medication 10
Name:
Dosage:
Frequency:
Photo:
Medication 11
Name:
Dosage:
Frequency:
Photo:
Medication 12
Name:
Dosage:
Frequency:
Photo:
Medication 13
Name:
Dosage:
Frequency:
Photo:
Medication 14
Name:
Dosage:
Frequency:
Photo:
Medication 15
Name:
Dosage:
Frequency:
Photo:
Medication 16
Name:
Dosage:
Frequency:
Photo:
Medication 17
Name:
Dosage:
Frequency:
Photo:
Medication 18
Name:
Dosage:
Frequency:
Photo:
Medication 19
Name:
Dosage:
Frequency:
Photo:
Medication 20
Name:
Dosage:
Frequency:
Photo:
Add Medication
Disciplines Needed:
SN
PT
ST
CHHA
OT
MSW
SN Frequency:
SN Frequency:
CHHA Frequency:
CHHA Frequency:
Treatment List:
IV
Wound Care
Ostomy Care
Catheter Care
Injections
Supplies Needed
Size-based Supplies
Gloves
Gloves Size:
Select Size
Small
Medium
Large
Pull Ups
Size:
Select Size
Small
Medium
Large
Other Supplies
Roll Aider
Shower Bench
Chux
Walker
Additional Supplies Needed
Additional Supplies Needed:
Additional Comments and Requests
Additional Comments and Requests:
Submit Assessment
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