Home Bound Status N/A

Bed Bound

Assist 1-2 Person

Restricted Activity

Not Home Bound

 Vital Signs

BP  Left | Right

Lying

Sitting

Standing

Temp  WT

AP  HT

RP

RR

  Mental Status

Stuporus

Forgetful

Disorented

Combative

WNL

Agitated

Comatose

Depressed

Lethargic

 CNS

Headache

Tremmors

tentinits

seizures

Paralysis

WNL

Syncope

Vertigo

Blurred Vision

Ataxia

Numbness

 Location  ______________________

Neuropathy

Hyperflexia

Delirium

 Sensory

WNL

Impaired Vision

Impaired Hearing

Aphasia EXP.

Aphasia REC.

Dysphasia

 Cardiovascular

Dysrhythrnia

Bradycardia

Cyanosis

NVD

Chest Pain

WNL

RLE + 1 2 3 4

LLE + 1 2 3 4

Pitting

Pacemaker

 Respiratory

Rales

Ronchi

IN Wheeze

Exp Wheeze

Decreased

Cough

O2

LT/Min_________

VIA

WNL

Left

Right

Left

Right

Left

Right

Left

Right

Left

Right

Sputum

Color___________
AMT___________

 IV Therapy Status

 Medication _______________

 Dose  _______________

 Frequency  _______________

 Duration _______________

Lab Orders   N/A

Test _______________

Frequency

 Integurnentary

Rash

Bruise

Jaundice

Pruritis

WNL

Petechiae

Clammy

Flushed

Pallor

Wound Descriptions*

Ulcer

ODW

Incision

 

*See Skin Assessment

 Gastrointestinal

Oral/WNL

Stomaitis

Bleeding Gums

Digestive/WNL

Abdominal Pain

Nausea/Vomiting

Dysphagia

B.S. Hypo/Hyper

Negative B.S.

WNL

Type  ______________________

Site     _____________________

Elimination\WNL

Colostomy

Illeostomy

Constipation

Bloody StoolIncontinent

Diarrhea

Impaction

Last BM

 Date ________

  Nutritional Status       WNL

Regular

Low Fat

Eternal

Parental

NA + Restriction      ______ gms

Protein Reset          ______ gms

Fluid Restriction     _______ ccs

Weight Loss

Weight Gain

 Amount In Pounds_____________

 Meals Prepared By:

Self

Family

Friend

Other

 Genitourinary

Urine / WNL

Frequency

Urgency

Incontinent

Catheter

   Type

   Size

Urine

   Color

   Odor

WNL

Polyuria

Nocturia

Hematuria

Burning

Pain

 Musculoskeletal

Amputation

Weakness

Unsteady Gait

ROM WNL

Decrease ROM

Fracture          Site ______

Paralysis         Site ______

Prosthesis       Site ______

  Pain Status

 Sites ____________________

 Intentsity

At Rest  1 2 3 4 5

Active  1 2 3 4 5

 Participating Factors

_______________________

Alleviating Factors

_______________________

Pain Regiment

_______________________

Efficy

Good

Moderate

Poor

  Functional & Mobility Status

Independent Amputation

Amputation /w Device

Walker Cane Crutches

Amputation /w Assist

 Amputation in Feet ___________

Independent Transfers

Transfers /w Assist

 Mobility Status Continued

Endurance WNL

Generalized Weakness

SOB /w Ambulation

      _____________Ft.

SOB /W Minimal Exertion

SOB /w Increase Activity

 

  Activities of Daily Living

1 - Independent 2=Supervised

3-Assist x1 4-Dependent

Bathing               _______

Dressing              _______

Toileting              _______

Meal Prep           _______

Housekeeping     _______

Driving                _______

Errands               _______

  Social Support Status

Lives Alone

Lives /w Spouse

Lives /w Other

 Family Support Yes No

 Langue Barrier Yes No

 Interpreter Yes No

Environmental /Safety Issues

Describe:_________________

 IV Catheter Status

Peripheral IV   Site _______

Central IV        Site _______

PICC Line       Site _______

Infusion Port   Site _______

Hickman Cath Site _______

Broviac Cath  Site _______

Insertion Date  ____________

 

Knowledge Assessment  Scoring Key     ( 1=Good  2-Fair  3=Poor )

 Knowledge of Diagnosis

 Patient          123

 PCGN/A 123

 Knowledge of Treatment

 Patient          123

 PCGN/A 123

 Ability to Participate

 Patient            123

 PCG  N/A 123

Willingness to Participate

Patient            123

 PCG  N/A 123

 Knowledge of Home Care Services

 Patient         123

 PCGN/A 123

 Knowledge of Community Resources

 Patient         123

 PCGN/A 123

Medical History
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