Transcription of Skilled Nursing Note - Matrix Home Care
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Skilled Nursing Note - Matrix Home Care
Skilled Nursing Note [ ] Initial Assessment [ ] Follow up visit [ ] Supervisory visit Name of Patient: _____ Date: _____. Vital Signs Ht: _____ Wt: _____ Temp: _____ Pulse: A/R: _____ [ ] Regular [ ] Irregular Resp: _____ B/P: _____ [ ] Lying [ ] Sitting [ ] Standing [ ] Right [ ] Left Nursing assessment and observation of signs/symptoms (Mark all applicable with an X or circle item(s) separated by / . CARDIOVASCULAR RESPIRATORY PAIN SKIN. [ ] WNL [ ] WNL [ ] None [ ] WNL [ ] Cellulitis [ ] Pressure sore [ ] Edema (Specify) [ ] Dyspnea/SOB [ ] Location: [ ] Rash [ ] Skin tear [ ] Wound [ ] Incision [ ] RUE [ ] LUE [ ] RLE [ ] LLE [ ] Cough/Sputum #1 #2 #3. 1/2/3/4+ [ ] Pitting [ ] Non-pitting [ ] Other: Severity (0-10): Length [ ] Other: Other: Width GENITOURINARY Depth EMOTIONAL STATUS [ ] WNL DIGESTIVE Drainage [ ] WNL [ ] Incontinence [ ] WNL Tunneling [ ] Disoriented [ ] Catheter/Size [ ] Nausea/Vomiting Odor [ ] Forgetful [ ] IIeostomy [ ] Difficulty Swallowing Sur tissue [ ] Depressed [ ] Other: [ ] Diarrhea/Constipation Wound bed [ ] Other: [ ] Colostomy Stoma: MUSCULOSKELETAL [ ] Incontinence [ ] WNL [ ] Last BM [ ] Steri-strips [ ] Sutures [ ] Staples NEUROSENSORY.)
Skilled Nursing Note [ ] Initial Assessment [ ] Follow up visit [ ] Supervisory visit Name of Patient: _____ Date: _____
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