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 / Intensity FontanelsNothing SelectedNormalFullSunkenBulgingSoftTenseN/AComments / Other RespiratoryRespirationsNothing SelectedNo DistressGruntingFlaringStridorRetractionsClear / Equil BilaterallySymmetrical Oxymetry Sats Sats Trach Vent CPAP Suction O2 O2 O2 @ L O2 Via Neb Treatments Cough Sputum Sputum Sputum: Amount / Color / Consistency / Odor Comments / Other CardiovascularCardio RhythmNothing SelectedRegularIrregularMurmurPulsesNothing SelectedNormalBondingWeak* Absent* If pulse absent, site appearance Capillary RefillNothing SelectedNormal* ProlongedLiverN/A* If prolonged: Time If palpable: In cm If edema: Explain Comments / Other GIBowel SoundsNothing SelectedNormalHypoactiveHyperactiveAbsentAbdomenNothing SelectedSoftFirmDistendedCurrent Weight Feeding Tubes Feeding Tube Via Status of Feeding Tube Placement Checked Tolerating Not Tolerating DietDiet NPO Last BM Other Tubes Comments / Other GUGU Voiding Color / Odor / Pain Catheter Catheter Catheter type / size Continence (May choose multiple responses)ContinentIncontinentDiaperComments / Other Endo / MetabolicBlood Sugars Blood Sugars Blood Sugar Description Controls Controls Controls Description Urine Glucose Urine Glucose Urine Glucose Description Comments / Other ClosingPatient / Caregiver Teaching*Degree of Mastery*Time / NarrativeStatus Upon Departure*Disposal of Waste Total Intake Total Output MD Orders / Care Plan Reviewed MD ContactNoYesSelect MD ContactResponse / Result Comments / OtherPhoneThis field is for validation purposes and should be left unchanged.
