Level of Care: □ Routine Home Care □ Inpatient

□ Continuous Care
□ Respite

HOSPICE NURSING
CLINICAL NOTE

IDG = IDG Care Plan Update Indicator

Patient Name

ID#

DX:

SKILLED OBSERVATION
VITAL SIGNS

CARDIOVASCULAR

RESPIRATORY

NEUROLOGICAL

PSYCHOLOGICAL

T ______________
P ______________
R ______________
Wt ______________
BP ___________right
___________left
Glucometer
BS ______________
□ Standard Precautions
Maintained

















□ No Deficit
□ Oriented to Person/
Place/Time
□ Seizures/Tremors

□ No Deficit

SENSORY
□ Hearing Impaired
□ Speech Impaired
□ Visually Impaired
□ Legally Blind
□ Unchanged since last
visit

No Deficit ___________________
Chest Pain __________________
Heart Sounds ________________
Peripheral Pulses _____________
Dizziness ___________________
Edema ______________________
Neck Vein Distention ___________
Arrhythmia __________________
Unchanged since last visit

Medication change since last visit?

No Deficit ___________________
Rale/Rhonchi ________________
SOB _______________________
Cough ______________________
Sputum _____________________
O2 at ________________________
O2 Sat _______________________
Other _______________________
Unchanged since last visit






GU



Confused
□ Restless


Depressed □ Drowsy

Tearful
□ Semi-Comatose


Withdrawn □ Comatose

Agitative
□ Lethargic

Hostile
□ Forgetful

Unchanged since last visit
□ Combative

No Deficit
Incontinent
Distention
Retention
Burning
Frequency
Foleycath
Suprapubic
Size _________ Fr
_________ ml
Unchanged since
last visit

□ No □ Yes, Specify ___________________________________________________________________________________________________________

SKIN

DIGESTIVE/NUTRITION

MUSCULOSKELETAL

□ No Deficit
□ Warm / Dry
□ No Deficit - Last BM _________________
□ Cool / Clammy □ Turgor Adequate □ N/V □ Diarrhea □ Constipation
Wound #1
Wound #2
□ Tube Feeding
□ NPO
Location
Location
Type/Amt. _________________
______________ ______________






□ ✓Placement □ ✓Residual/Amt. ______ □
□ Bowel Sounds Present

L _____________ L _____________
W ____________ W ____________
D_____________ D_____________
Wound Bed
Wound Bed
Color ________
Color ________
Tissue________
Tissue________
Drainage _______ Drainage _______
Amt _________
Amt _________
Odor_________
Odor_________
□ Unchanged since last visit

□ Abd. Girth _________________________ □
□ Diet ______________________________ □

□ Meals Prepared & Administered

Appropriately

□ Ascites


□ Unchanged since last visit

PAIN

No Deficit
Weakness
Balance/Gait Abnormal
Limited Mobility/ROM
Pain
Grip Strength
right _____ left _____
Bedbound
Chairbound
Contracture
Paralysis
Assistive/Device
Fall Precautions maintained
Unchanged since last visit 

See Additional Pain

Primary Site ________________________

*

No Hurt

Hurts
Little Bit

Hurts
Little More

Hurts
Even More

Hurts
Whole Lot

Hurts
Worst

0

2

4

6

8

10

Assessment/Documentation
(per agency policy)
Refer to:

Duration _______________________________

INFUSION

Frequency ______________________________

□ IV Tubing Change

Character ______________________________

□ Cap Change

Current pain management & effectiveness:

□ Central Line Dressing Change

__________________________________

□ IV Site Dressing Change

□ Pain Management Teaching to
patient/family (document below)

□ IV Site Change
□ Infusion by

Patient’s pain goal/outcome:
__________________________________
□ Unchanged since last visit

__________________ Pump
□ Infusion

SKILLED INTERVENTION /TREATMENT/ TEACHING / Pt / Cg RESPONSE

SUPERVISION

Patient’s pain was brought to a comfortable level within 48 hours of initial assessment:  NA  Yes  No Describe:

□ LPN

□ Aide q 14 days

□ Other __________________________
Patient unable to self report due to:  Discharge 

Condition deteriorated/No longer able to communicate  Other: _________________________

IDG CHANGES SINCE LAST VISIT:
Physical Needs: 

No  Yes Describe:

ed. 8, St. Louis, 2009, Mosby. Used with permission. Copyright Mosby.

* From Hockenberry MJ, Wilson D: Wong’s essentials of pediatric nursing,

Interventions:

Psychosocial Needs:  No  Yes Describe:
Interventions:

Present on this visit?

□ Yes □ No

Aide following care plan?

□ Yes □ No

Aide following infection
control?

□ Yes □ No

Good interpersonal
relationships?

□ Yes □ No

Report changes in patient
status to Hospice?

□ Yes □ No

Patient satisfied with care?

□ Yes □ No

Changes made to aide
care plan?

□ Yes □ No

Aide reports emergencies?

□ Yes □ No

Additional instruction
given during visit?

□ Yes □ No
□ Yes □ No

Emotional Needs: 

No  Yes Describe:

Aide is competent to
provide care?

Spiritual Needs: 

No  Yes Describe:

Signature:

Interventions:

COORDINATION / PLAN
Progress To Goals/Outcomes: ______________________________________________________________________________________________________________________________________
Title of Teaching Tool used/given: _________________________________________________________________ □ Instructed □ Pt/Cg. Verbalized Understanding □ Pt/Cg. Return Demonstration
Care Coordinated/Conferenced with: □ SN □ PT □ OT □ SLP □ SW □ Aide □ SCC □ Volunteer □ Counselor □ Dietitian

Name: _______________________________________

Regarding: ___________________________________________________________________________________________________________________ Date/Time _________________________
Educated Regarding:

Infection Control:

□ Yes

□ No

Equipment Safety:

□ Yes

□ No

Dietary Counseling: ______________________________________________________________________________________________________________________________________________
Physician Contacted Re: ______________________________________________________________________________________________________ Date/Time _________________________
Order Changes: __________________________________________________________________________________________________________________________________________________
Plan For Next Visit: _______________________________________________________________________________________________________________________________________________
Pt/Cg Response to Care: □ Satisfactory

□ Not Satisfactory

Nurse Signature & Title

Comments: ________________________________________________________________________________________________
Time In

Time Out

Patient/Caregiver Signature (optional per agency policy)

Date
Date

Signature Validates Nursing Visit Date and Time

Form# HC8001-N

(Rev. 07/14)

© 1999 MED-PASS, Inc.

WHITE – Clinical Record

YELLOW – Office Copy

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