SN VISIT

Situation: Patient is seen for skilled assessment, disease/med management, monitoring, and teachings.

Background:

Assessment: Patient is agreeable with POC. COVID precaution and infection control observed; clean bag
technique used; Head to toe assessment done, heart and lungs auscultation done, VS checked. Patient’s
spouse, and son are present during SN visit. Patient is seen in the living room. Reminded patient/CG to
call Home Health with any medical concerns before going to ER; to call 911 for severe chest pain, SOB,
any s/s of neurological deficit, uncontrolled bleeding or pain, any neurological deficits, and/or any life-
threatening ER; Patient/caregiver verbalized understanding.

Recommendations: SNV for skilled assessment; disease/med management; monitoring, and teachings;

SN DC: Patient is seen for skilled assessment/evaluation, disease/medication management, teachings,

and discharge. Patient is agreeable with POC. Head to toe assessment done, heart and lungs
auscultation done, VS.checked. Patient is seen in her dining area. Patient appears calm and comfortable.
No complaints of uncontrollable pain; no non verbal cues of pain noted. No complaints of chest pain. No
SOB; respiration is even and non labored. Made patient aware that patient's condition is improved and
stabilized, and that patient is being discharged from Home Health Services today. Patient verbalized
understanding. Patient is agreeable with POC. Patient stated she has been doing very well. Patient
reports compliance with medications. No significant change reported by patient. No significant change
noted during SN visit. Instructed patient to keep scheduled appointment with PCP regularly, to continue
to take medications as prescribed by her MD, to not take OTC meds without MD approval, to continue
with home program as instructed by therapist, to always use her assistive device when ambulating - to
prevent fall, to follow the diet as prescribed by her MD. Reinforced teachings on disease process; HTN;
UTI prevention; Cardiopulmonary management; s/s to report to MD/SN; improving nutritional status;
proper medication administration and importance of compliance; infection control; fall prevention and
safety precaution; use of assistive device for support and safety; pressure ulcer prevention; accident
prevention. Educated patient to call and activate 911 for severe chest pain, SOB, uncontrollable bleeding
or pain, and for any life threatening situation at home. Patient/caregiver verbalized understanding.
Patient's condition is stable.

NOMNC DAY:

Situation: Patient is seen for skilled assessment, disease/med management, teachings.

Background:

Assessment: The patient is agreeable with POC. COVID precaution and infection control observed; clean
bag technique used; Head to toe assessment done, heart and lungs auscultation done, VS checked. The
patient’s spouse and son are present during the SN visit. The patient is seen in the living room. The
patient appears calm and comfortable. No complaints of uncontrollable pain; no non-verbal cues of pain
were noted. No complaints of chest pain. No SOB at rest; respiration is even and non-labored. The
patient specifically denies fever, chills, cough, nausea and vomiting, diarrhea, dysuria, chest pain, or
shortness of breath. Patient reports compliance with medications. No significant change was reported
by the patient/caregiver. No significant change was noted during the SN visit. Made the patient aware sn
visit after that the patient's condition is improved and stabilized, and that POC is for the patient to be
discharged from Home Health Services next SNV. The patient verbalized understanding. The patient is
agreeable with POC. NOMNC was discussed/explained by SN and signed by the patient. Reminded
patient/CG to call Home Health with any medical concerns before going to ER; to call 911 for severe
chest pain, SOB, any s/s of neurological deficit, uncontrolled bleeding or pain, any neurological deficits,
and/or any life-threatening ER; Patient/caregiver verbalized understanding.

Recommendations: SNV for skilled assessment; disease/med management; teachings; Discharge from
Home Health Services

SOC:

ADMISSION CONSENTS REVIEWED AND OBTAINED. PATIENT INFORMATION BOOKLET PROVIDED FOR
REVIEW. EMERGENCY PLAN REVIEWED. ADVANCED DIRECTIVES INFO PROVIDED, FOR REVIEW AND TO
LET RN/MD KNOW IF NEED ASSISTANCE IN COMPLETING THE FORM. VACCINATION REVIEWED AND
STRESSED IMPORTANCE OF KEEPING UP TO DATE IMMUNIZATIONS. INFO PROVIDED ON OFFICE HOURS
AND ON-CALL HOURS FOR NON-URGENT CALLS, AND FOR PATIENT/CG TO DIAL 911 FOR EMERGENCY
CALLS. SITUATION: SOC on (date) to a/e patient status after ….discharged from (what hospital?/what
rehab?) on ______ (date?), ________ (reason for hospitalization). Patient was referred to home health
for (reason for referral/admission to home health). If MD referral… from which MD? Patient referred to
home health for (reason for referral/admission to home health).

PATIENT GOAL: no hospitalization; no falls; intact skin;

WHAT ARE HIS/HER STRENGTHS PER PATIENT: motivated learner; strong support system; enhanced
socioeconomic status

CODE STATUS: FULL/DNR

BACKGROUND: Patient is a __ year old (male/female) with the following medical history:

ASSESSMENT: VS- BP____, HR____, RR ___, O2 sat ____, temp _____, WEIGHT/MAC ______ (any
concerns?)

Pain: Patient has chronic back, joints, and neck pain relieved by meds and rest.

Neuro/mental status: Patient is A/O x3; PERRLA; verbally responsive and is able to make needs known;
pleasant, cooperative, forgetful.

Cardio: Heart sounds regular rate/rhythm; all peripheral pulses palpable; no edema noted; no JVD;
denies dizziness; chest pain

Respiratory: Bilateral lungs clear to auscultation; productive cough; respiration is even and non labored;
no SOB noted at rest, tolerates room air. Patient's noted with SOB with moderate exertion.

GI/GU: Abdomen is soft and non distended; noted with normal active bowel sounds on all quadrants;
last BM known on 08/28/2020 per patient; no complaints of constipation nor diarrhea; no N/V. Bladder
is soft and non distended; patient denies having pain/burning sensation upon urination; patient denies
having s/s of UTI. Patient is incontinent of both bowel and bladder; utilizes adult brief for protection and
to not rush to restroom.
Nutrition: Patient is on _______ diet; able to feed self after meal set up.

Skin: Patient's skin is clean, dry, warm to touch; intact; noted with puncture site on right femur area; no
s/s of infection noted upon assessment; bruise noted around the puncture site; patient's also noted with
bruise on left upper arm area. Patient's noted with amputation of all toes on left foot. Patient is at risk
for skin breakdown.

Endocrine: Glucose level is monitored on a daily basis by patient before breakfast; glucose level this am
per patient was 90mg/dL; no s/s of hypo/hyperglycemia noted during visit.

Medications: All medications reconciled for patient’s safety, med list written out and left in folder,
medications are managed by patient/family/caregiver

MS/Functional: Patient's able to move all extremities, weak, able to stand up, ambulatory with FWW,
noted with unsteady gait/balance, high risk for falls. Patient requires moderate assistance with ADL and
transfers. Patient currently lives alone. Patient has a brother and a sister.

Environment/Social dynamics: any hazards/issues/challenges causing concerns?

TEACHING PROVIDED: Disease process; pain management; DM management; Cardiopulmonary

management; s/s to report to MD/SN; improving nutritional status; proper medication administration;
infection control; fall and safety precaution; safe and proper use of oxygen; use of assistive device for
support and safety; pressure ulcer prevention; accident prevention. Educated patient/CG to call Home
Health with any medical concerns before going to ER; to call 911 for severe chest pain, SOB,
uncontrollable bleeding/pain, and any life threatening events. Patient/caregiver verbalized
understanding.

RESPONSE TO TEACHING:

MEDICATION ISSUES/DISCREPANCIES/RECENT MEDICATION CHANGES:

ANY ADDITIONAL COORDINATION WITH MD?: POC on SOC; skilled assessment; spoke with

DME IN HOME:

SUPPLIES IN HOME:

CAREGIVER WILLINGNESS AND ABILITY TO CARE FOR PATIENT: able and willing

CAREGIVER SCHEDULE:

RECOMMENDATION: Skilled nursing visits (FREQUENCY) to a/e (focus of care) skilled assessment;
diseaese/med management; wound care and management;

- Physical therapy eval for mobility, safety and home exercise program

- Occupational therapy for IADL/ADL training, safety and DME recommendations.

-Medical social therapy evaluation to refer to community resources

-Speech therapy evaluation for ….speech/cognition/swallowing.

- Home Health Aide (frequency) to assist with personal care

SITUATION: Recertification for continued homebound status and skilled need for (reason for
recertification- why do we need to extend services, why were goals not met previously?)…recent
medication changes- what medication, what was changed, when was it changed?, complex wound care-
etiology of wound, location, treatment, is wound progressing? if not, why and what was done about it? ,
IV care and management with weekly PICC line dressing changes and labs, need for monitoring d/t
unstable health status with unmanaged symptoms r/t- CHF/DM/COPD and/or need for patient/caregiver
education/teaching and training r/t- medication regimen, disease process r/t- CHF/DM/COPD and/or
safety

PLAN FOR ACCOMPLISHING GOALS:

CODE STATUS:

FULL/DNR

BACKGROUND: Patient is a __ year old (male/female) with the following medical history: - primary and
comorbidities

ASSESSMENT: VS- BP____, HR____, RR ___, O2 sat ____, temp _____, WEIGHT/MAC ______ (any
concerns?)

Pain: Patient has chronic back, joints, and neck pain relieved by meds and rest.

Neuro/mental: Patient is A/O x3; PERRLA; verbally responsive and is able to make needs known;
pleasant, cooperative, forgetful.

Cardio: Heart sounds regular rate/rhythm; all peripheral pulses palpable; no edema noted; no JVD;
denies dizziness; chest pain

Respiratory: Bilateral lungs clear to auscultation; productive cough; respiration is even and non labored;
no SOB noted at rest, tolerates room air. Patient's noted with SOB with moderate exertion.

GI/GU: Abdomen is soft and non distended; noted with normal active bowel sounds on all quadrants;
last BM known on 08/28/2020 per patient; no complaints of constipation nor diarrhea; no N/V. Bladder
is soft and non distended; patient denies having pain/burning sensation upon urination; patient denies
having s/s of UTI. Patient is incontinent of both bowel and bladder; utilizes adult brief for protection and
to not rush to restroom.

Nutrition: Patient is on _______ diet; able to feed self after meal set up.

Skin: is skin is clean, dry and intact? Is patient at risk for skin breakdown? - if so, caused from what?
Does patient have a wound? - if so, what type, located where, what was treatment and how was it
tolerated? Does patient have any other skin issues- what are they? Patient's skin is clean, dry, warm to
touch; intact; noted with puncture site on right femur area; no s/s of infection noted upon assessment;
bruise noted around the puncture site; patient's also noted with bruise on left upper arm area. Patient's
noted with amputation of all toes on left foot. Patient is at risk for skin breakdown.

Endocrine: Glucose level is monitored on a daily basis by patient before breakfast; glucose level this am
per patient was 90mg/dL; no s/s of hypo/hyperglycemia noted during visit.

Medications: All medications reconciled for patient’s safety, med list written out and left in folder,
medications are managed by patient/family/caregiver

MS/Functional: Patient's able to move all extremities, weak, able to stand up, ambulatory with FWW,
noted with unsteady gait/balance, high risk for falls. Patient requires moderate assistance with ADL and
transfers. Patient currently lives alone. Patient has a brother and a sister.

Environment/Social dynamics: any hazards/issues/challenges causing concerns?

TEACHING PROVIDED: Disease process; pain management; DM management; Cardiopulmonary

management; s/s to report to MD/SN; improving nutritional status; proper medication administration;
infection control; fall and safety precaution; safe and proper use of oxygen; use of assistive device for
support and safety; pressure ulcer prevention; accident prevention. Educated patient/CG to call Home
Health with any medical concerns before going to ER; to call 911 for severe chest pain, SOB,
uncontrollable bleeding/pain, and any life threatening events. Patient/caregiver verbalized
understanding.

RESPONSE TO TEACHING:

ANY OTHER COORDINATION WITH MD?: RECOMMENDATION: Skilled nursing visits (FREQUENCY) to
(focus of care)

- Physical therapy (why continuing or adding?)

- Occupational therapy (why continuing or adding?)

-Medical social therapy (why continuing or adding?)

-Speech therapy (why continuing or adding?)

- Home Health Aide (why continuing or adding?)

DISCHARGE INSTRUCTIONS Provided understandable discharge instructions for the patient and family,
explanation of self care activities, list of community and out patient resources and referrals, medication
reconciliation done. Discharge Instructions verbally reviewed with patient and CG and are as follows:
Keep scheduled appointment with PCP regularly - every 4-6 weeks. Continue to take medications as
prescribed by your MD. DO NOT take OTC meds without MD approval. Continue with home program as
instructed by therapist. Always use your assistive device when ambulating - to prevent fall. Follow the
diet as prescribed by MD. Infection control, universal precautions and the importance of frequent hand
washing.
Care Summary Patient is admitted to Home Health Services for skilled assessment and for disease and
medication management. Patient is seen by SN, PT, OT, ST, HHA, and MSW. Patient's clinical condition
and functional status is improved and stabilized. All goals are met. Patient is discharged from Home
Health Services. Patient is admitted to Home Health Services for skilled assessment and for disease and
medication management. Patient is seen by SN, PT, and OT. Patient's physical and clinical condition
unstable; patient has deterioration of both clinical condition and functional status. Patient is transferred
to hospital due to…

SOC TEMPLATE EMAN

ADMISSION CONSENTS REVIEWED AND OBTAINED. PATIENT INFORMATION BOOKLET PROVIDED FOR
REVIEW. EMERGENCY PLAN REVIEWED. ADVANCED DIRECTIVES INFO PROVIDED, FOR REVIEW AND TO
LET RN/MD KNOW IF NEED ASSISTANCE IN COMPLETING THE FORM. VACCINATION REVIEWED AND
STRESSED IMPORTANCE OF KEEPING UP TO DATE IMMUNIZATIONS. INFO PROVIDED ON OFFICE HOURS
AND ONCALL HOURS FOR NON-URGENT CALLS, AND FOR PATIENT/CG TO DIAL 911 FOR EMERGENCY
CALLS.

SITUATION: SOC on 06/28/2023 to a/e patient status after discharged from SFDPH hospital due to
generalized body weakness, metastatic left breast CA on 06/27/2023. Patient was referred to home
health for skilled nurse instruction on complex disease process and management, physical therapy for
skilled intervention in falls prevention measures, safety and mobility, therapeutic exercises,
occupational therapy for skilled instruction in safety, ADLs, and assistive equipment, MSW for
community resources and IHSS f/u and HHA for personal care.

PATIENT GOAL: Prevent patient from hospitalization. WHAT ARE HIS/HER STRENGTHS PER PATIENT:
Motivated learner and strong support system.

CODE STATUS: FULL CODE

MD APPT:

BACKGROUND: Patient is a 66-year-old male with the following medical history: metastatic cancer,
trigger finger, leukopenia, sleep difficulties, essential thrombocythemia, GERD, anemia

ASSESSMENT:

VS- temp: 98.1 HR: 86 bpm RR: 18 cpm BP: 117/60 mmHg O2 saturation: 99% weight:135 lbs. height: 66
inches

Pain: Patient reported pain on his left leg and hip with a pain scale of 8/10, constant and aching, daily
and constant, worsen upon movement, pain manage by rest and medication.

Neuro/mental status- Patient is alert and oriented x 4, pleasant calm, and cooperative. In no acute
distress. Conversant and friendly affect. No depressive symptoms, no changes in thought content.
Normal speech, speaking in full sentences, follows commands appropriately, face symmetric. noted with
weakness on the left side and hand grip strength was not equal.
Cardio: the patient has a regular rate and rhythm, no JVD present, and noted +1 edema patient's
bilateral lower extremities. Patient denies chest pain, dizziness and palpitation.

Respiratory: Lungs are clear to auscultation on all lobes/ no wheezes/ no rhonchi/no rales/no stridor, no
cough, no SOB at rest but patient mentioned SOB when walking more than 20 feet, does not use oxygen
supplement. SOB is managed with non-pharmacological management such as pacing, purse lip
breathing, avoiding exposure to pollutants in the air, and energy conservation.

GI/GU: Patient's bowel sounds are active x4 quadrants, the abdomen is soft to touch, and not distended,
and the last BM known was today 06/28/2023, normal in appearance, denies diarrhea and constipation
during the assessment but reported to have occasional constipation manage by PRN laxative. Patient has
urinary incontinence but denies urgency and pain or burning sensation upon urination, voiding freely to
clear yellow urine. Patient does use incontinence supplies.

Nutrition: Patient is on a regular diet. No nausea and vomiting reported during the assessment.

Skin: Skin is clean, dry, and intact. No rashes or wounds noted.

Endocrine: Patient is not diabetic, No history of hypothyroidism/hyperthyroidism.

Medications: All medications reconciled, a med list written out and left in a folder, medications are
managed by the patient by utilizing medication bottles.

MS/Functional: Patient able to stand and ambulate with minimal to moderate assistance, noted with
unsteady balance and decreased balance strength from left upper and Lower extremity weakness due to
current condition and comorbidities. Patient requires minimal to moderate assistance with ADLs/IADLs.
Patient is using cane/walker inside the house as an assistive device. Patient is currently living alone.

Environment/Social dynamics: stairs

TEACHING PROVIDED/RATIONALE FOR TEACHING: Education provided on the importance of medication

compliance, medication use, dose, frequency, and side effects; SN educated patient and caregiver on the
importance of always using assistive device with ambulation and transfers to avoid falls or injuries.
Nurse instructed patient and caregiver on the importance of home safety such as proper lighting, and to
keep walkways free of debris and clutter. Patient was instructed to contact PCP or home health agency if
they fall or if current health status declines. Patient was instructed to not walk unassisted when not
feeling steady. Educated patient/CG to call Home Health with any medical concerns before going to ER;
to call 911 for severe chest pain, SOB, uncontrollable bleeding/pain, and any life-threatening events.
Patient/caregiver verbalized understanding. RESPONSE TO TEACHING: Patient verbalized understanding
and will comply.

MEDICATION ISSUES/DISCREPANCIES/RECENT MEDICATION CHANGES: Yes Patient is taking Metamucil

for constipation that is not in the medication list.

ANY ADDITIONAL COORDINATION WITH MD: Called PCP office and informed patient is admitted to HH,
SOC, POC and medication discrepancy.

DME IN HOME: Walker, shower chair, cane, wheelchair SUPPLIES IN HOME: Incontinence supplies
CAREGIVER WILLINGNESS AND ABILITY TO CARE FOR PATIENT: Patient is living alone

Pacific interpreter

855-469-5222.

Health Link SF & Peninsula

868 Brannan St.
Suite 307
San Francisco, CA 94103

Phone: 415.664.5500
Fax: 415.664.4003
Email: care@healthlinkhha.com