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Withdrawn Comatose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

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

Patients pain goal/outcome:

__________________________________
Unchanged since last visit

__________________ Pump
Infusion

SKILLED INTERVENTION /TREATMENT/ TEACHING / Pt / Cg RESPONSE

SUPERVISION

Patients 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: Wongs 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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