Home Care Client Progress Note Home Care Client Progress Note For patient assessment by provider. 1Intro2Skin3Neuromuscular / Behavioral4Respiratory5Cardiovascular6GI7GU8Endo / Metabolic9Closing INTRONurse's Name* First Last RN / LPN*Client Name* First Last Date of Service* MM slash DD slash YYYY Time In* : Hours Minutes AM PM AM/PM Time Out : Hours Minutes AM PM AM/PM Episode ID#* SkinSkin IntegrityNothing SelectedIntactBruisingDrynessRashWoundDrainageSkin TempNothing SelectedWarmCoolDiaphoreticSkin TurgorNothing SelectedNormalLooseTautOral CavityNothing SelectedMoistDryCrackedSoresComments / Other Neuromuscular / BehavioralActivity StateNothing SelectedActiveQuiet / AlertCryingLethargicSleepingUnresponsiveSeizuresPERRLAExtremitiesNothing SelectedEqualUnequalWeaknessFlaccidRigidSpasticNormalPain*NoneYes** If YES: Location / IntensityFontanelsNothing SelectedNormalFullSunkenBulgingSoftTenseN/AComments / Other RespiratoryRespirationsNothing SelectedNo DistressGruntingFlaringStridorRetractionsClear / Equil BilaterallySymmetrical Oxymetry Sats Sats Trach Vent CPAP Suction O2 O2 O2 @ LO2 Via Neb Treatments Cough Sputum Sputum Sputum: Amount / Color / Consistency / OdorComments / Other CardiovascularCardio RhythmNothing SelectedRegularIrregularMurmurPulsesNothing SelectedNormalBondingWeak* Absent* If pulse absent, site appearanceCapillary RefillNothing SelectedNormal* ProlongedLiverN/A* If prolonged: TimeIf palpable: In cmIf edema: ExplainComments / Other GIBowel SoundsNothing SelectedNormalHypoactiveHyperactiveAbsentAbdomenNothing SelectedSoftFirmDistendedCurrent WeightFeeding TubesFeeding Tube ViaStatus of Feeding Tube Placement Checked Tolerating Not Tolerating DietDiet NPO Last BMOther TubesComments / Other GUGU Voiding Color / Odor / PainCatheter Catheter Catheter type / sizeContinence (May choose multiple responses)ContinentIncontinentDiaperComments / Other Endo / MetabolicBlood Sugars Blood Sugars Blood Sugar DescriptionControls Controls Controls DescriptionUrine Glucose Urine Glucose Urine Glucose DescriptionComments / Other ClosingPatient / Caregiver Teaching*Degree of Mastery*Time / NarrativeStatus Upon Departure*Disposal of WasteTotal IntakeTotal Output MD Orders / Care Plan Reviewed MD ContactNoYesSelect MD ContactResponse / ResultComments / OtherNameThis field is for validation purposes and should be left unchanged.
