"Nursing Home Progress Note - University of Virginia Health System"

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PATIENT NAME
MR#
NURSING HOME PROGRESS NOTE
o Initial Visit o Acute Care o Recertification o Annual Exam
Date:
ADDRESSOGRAPH
Advance Directives o Yes o No
ROS: Constitutional o neg
HPI: CC: Recent problems
Eyes o neg
Allergies
Problem List: o Reviewed o Updated
ENT, Mouth o neg
Respiratory o neg
HISTORY:
History obtained from: o Patient o Family
Cardiovascular o neg
o Nursing Staff o Chart o Therapy Staff
GI o neg
PMHx:
GU o neg
N
Neuro o neg
Social/Family Hx
U
MS o neg
R
Psych o neg
FUNCTIONAL STATUS
Ambulation
S
Basic ADLs Indep. Needs Asst. Dep.
o Nonambulatory
o With Cane
o Unassisted
Other
o
o
o
Transfers
o With Assistance
o With walker
I
MEDICATIONS: o Reviewed
o
o
o
Feeding
o
o
o
Continence
Bathing
Continent
Incontinent
N
Recent Changes
o
o
o
o
o
Dressing
Urine
G
o
o
o
o
o
Grooming
Bowel
o GT
o Urinary Catheter
o Trach
o O2
PHYSICAL EXAM / CLINICAL DATA T _______ P_______ BP_______/_______
Wt:
H
Other
O
GENERAL APPEARANCE
M
HEENT o EOM Intact o Eyes Clear o No erythema, exudate or leison o TM intact o Good dentition Other
E
NECK o Neck symmetrical, no masses, trachea midline o Thyroid not enlarged, non-tender Other
CARDIOVASCULAR o RRR o Normal S
o S
o S
o No murmur
& S
P
1
2
3
4
RESPIRATORY o Bilaterally clear to auscultation
R
O
GI o Soft, non-tender o Bowel sounds present o No Mass o No Organomegaly
G
EXTREMITIES o No cyanosis, clubbing or edema
R
NEURO o A&O X 3 o CN Intact o Motor 5/5 o Sensations Intact o Reflexes normal/symmetric Gait
E
SKIN
S
OTHER
S
LAB
N
o Total Care Plan/Pharmacy/Medication Orders Reviewed
o Labs Reviewed
o Radiology Reviewed
O
ASSESSMENT & PLAN
T
E
Continues to need nursing facility care for
NP/Resident’s Signature
Date
o I saw and examined the patient. I agree with/revise
’s history, exam and assessment and plan.
Attending Signature
Date
Copy 1: OFFICE CHART Copy 2: NURSING HOME
001002 PILOT (1/01) To reorder call 924-5681
PATIENT NAME
MR#
NURSING HOME PROGRESS NOTE
o Initial Visit o Acute Care o Recertification o Annual Exam
Date:
ADDRESSOGRAPH
Advance Directives o Yes o No
ROS: Constitutional o neg
HPI: CC: Recent problems
Eyes o neg
Allergies
Problem List: o Reviewed o Updated
ENT, Mouth o neg
Respiratory o neg
HISTORY:
History obtained from: o Patient o Family
Cardiovascular o neg
o Nursing Staff o Chart o Therapy Staff
GI o neg
PMHx:
GU o neg
N
Neuro o neg
Social/Family Hx
U
MS o neg
R
Psych o neg
FUNCTIONAL STATUS
Ambulation
S
Basic ADLs Indep. Needs Asst. Dep.
o Nonambulatory
o With Cane
o Unassisted
Other
o
o
o
Transfers
o With Assistance
o With walker
I
MEDICATIONS: o Reviewed
o
o
o
Feeding
o
o
o
Continence
Bathing
Continent
Incontinent
N
Recent Changes
o
o
o
o
o
Dressing
Urine
G
o
o
o
o
o
Grooming
Bowel
o GT
o Urinary Catheter
o Trach
o O2
PHYSICAL EXAM / CLINICAL DATA T _______ P_______ BP_______/_______
Wt:
H
Other
O
GENERAL APPEARANCE
M
HEENT o EOM Intact o Eyes Clear o No erythema, exudate or leison o TM intact o Good dentition Other
E
NECK o Neck symmetrical, no masses, trachea midline o Thyroid not enlarged, non-tender Other
CARDIOVASCULAR o RRR o Normal S
o S
o S
o No murmur
& S
P
1
2
3
4
RESPIRATORY o Bilaterally clear to auscultation
R
O
GI o Soft, non-tender o Bowel sounds present o No Mass o No Organomegaly
G
EXTREMITIES o No cyanosis, clubbing or edema
R
NEURO o A&O X 3 o CN Intact o Motor 5/5 o Sensations Intact o Reflexes normal/symmetric Gait
E
SKIN
S
OTHER
S
LAB
N
o Total Care Plan/Pharmacy/Medication Orders Reviewed
o Labs Reviewed
o Radiology Reviewed
O
ASSESSMENT & PLAN
T
E
Continues to need nursing facility care for
NP/Resident’s Signature
Date
o I saw and examined the patient. I agree with/revise
’s history, exam and assessment and plan.
Attending Signature
Date
Copy 1: OFFICE CHART Copy 2: NURSING HOME
001002 PILOT (1/01) To reorder call 924-5681