Skilled Nursing Note Form

Initial Assessment

Follow up visit

Supervisory visit

Name of Patient *

Date *

Height

Weight

Temperature

Pulse: A/R:

Regular

Irregular

Nursing assessment and observation of signs/symptoms (Mark all applicable with an “X” or circle item(s) separated by “/”

Neurosensory

WNL

Syncope/Vertigo

Visual Impairment

Other

Supervisory Visit

Follows Std Precautions

Yes

Follows Plan of Care

Yes

Performs Care Properly

Yes

Patient satisfied

Yes

HHA Present

Yes

Recent history pertinent to reason for visit

Patient is homebound

Why?

Wound Care Performed

Aseptic technique

Sterile technique

Cleansed with NS

Product applied

Approximate Drainage in canister

Color

IV Therapy

Drug Give Name

Drug Dosage

Drug Via

Drug Over Minutes

Flushed line

Before

After meds/blood draw

Final flush with Heparin

U/CC

MLS

Peripheral IV inserted

Catheter

Type

Length

Lab draw of

From (site)

Taken to (Lab name)

Administered

SQ Site

Pt or CG taught to administer

Bowel Bladder

Suppository Used

Digital Stimulation Results

Written instructions given re

Other

Patient/Caregiver unable to be independent in care due to

Physical limitations

Learning limitations

Refuses to learn

N/A Pt/CG are independent

I certify that the ICARE Team Home Health Care, LLC Employee listed on this note worked the times indicated and the work was performed in a satisfactory manner.

Time In

Time Out

Parent Name *

Date *

Caregiver Name *

Date *

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Lying	Sitting	Standing
Right	Left

WNL	Edema(Specify)	RUE
LUE	RLE	LLE 1/2/3/4+
Pitting	Non-Pitting	Other

WNL	Cellulitis	Pressure Sore	Rash
Skin Tear	Wound	Incision

	Number 1	Number 2	Number 3
Length
Width
Depth
Drainage
Tunneling
Odor
Sur Tissue
Wound Bed

WNL	Disoriented	Forgetful
Depressed	Other

WNL	Nausea/Vomiting	Difficulty Swallowing	Diarrhea/Constipation
Colostomy	Incontinence	Last BM

WNL	ROM: RUE LUE RLE LLE	Unsteady Gait
Generalized Weakness	Other

Clear pathways/safe ambulations	Fall Precautions	Home Safety	Medication Management
IV Safety	Sharps Disposal	Oxygen Safety	Bleeding Precautions
Infection Control	Other

Bathing	Grooming	Dressing	Eating
Transferring	Patient/Client independent in ADL's

Assessment	Teaching/Training	Wound Care
IV Therapy	Lab Draw	HHA/Companion services
PT/OT/ST/MSW services	Medication Management	Other

Teaching/training	Medication regimen, actions, side effects	Disease process
Bleeding precautions	Wound/incision care	IV therapy
Infection control measures	Complications to report	Physician follow up
Home safety	Oxygen safety	Diet
Elevating legs to decrease edema	Off loading techniques	Sharps disposal
Plan of care review	Medication management	Inability to void post foley removal
Discharge instructions

Gauze	ABD pad	Telfa	Packed
Wet to dry-NS	Secured with tape/ace wrap/stockinette	Wound vac applied with	Black
White	Silver foam	Canister changed	Constant suction
Intermittent suction	Pressure	Approx. drainage in canister

alcohol	betadine	chloraprep line dressing changed on using sterile technique	alcohol swabs
3 provodine swabs	chloraprep swab	antimicrobial patch Applied	Occlusive dressing
Gauze dressing	Extension set	Injection site	Site free of complications
Flushes easily	Good blood return	Line removed (type)	Length
Tip intact	Pressure dressing applied

Foley catheter inserted	Leg bag	Bedside drainage bag
Foley removed without incident	Instructions given regarding complications to report	Bowel program performed
See communication sheet for addendum notes

Patient tolerated interventions well	Patient /CG verbalized/demonstrated understanding of instructions provided reason for visit independent with
Wound care	IV therapy
Medication management	Wound/ incision healing without complications
Tolerating medications without side effects or adverse reactions	atient will follow with physician as instructed
Discharge/no other nursing visits needed/ordered	Other

Steri-strips	Sutures	Staples
JP Drain	IV line Type