* = Required Information
Initial Assessment Follow up visit Supervisory visit

Vital Signs

Regular Irregular
Lying Sitting Standing
Right Left

Nursing assessment and observation of signs/symptoms (Mark all applicable with an “X” or circle item(s) separated by “/”

WNL Edema(Specify) RUE
LUE RLE LLE 1/2/3/4+
Pitting Non-Pitting Other
WNL Dyspnea/SOB Cough/Sputum Other
None Location Other
WNL Cellulitis Pressure Sore Rash
Skin Tear Wound Incision
  Number 1 Number 2 Number 3
Sur Tissue
Wound Bed
WNL Disoriented Forgetful
Depressed Other
WNL Incontinence Catheter/Size
IIeostomy Other
WNL Nausea/Vomiting Difficulty Swallowing Diarrhea/Constipation
Colostomy Incontinence Last BM
Steri-strips Sutures Staples
JP Drain IV line Type
WNL Syncope/Vertigo Visual Impairment Other
Generalized Weakness Other
Clear pathways/safe ambulations Fall Precautions Home Safety Medication Management
IV Safety Sharps Disposal Oxygen Safety Bleeding Precautions
Infection Control Other

Supervisory Visit

Yes No
Yes No
Yes No
Yes No
Yes No
Bathing Grooming Dressing Eating
Transferring Patient/Client independent in ADL's
Assessment Teaching/Training Wound Care
IV Therapy Lab Draw HHA/Companion services
PT/OT/ST/MSW services Medication Management Other
Patient is homebound
Teaching/training Medication regimen, actions, side effects Disease process
Bleeding precautions Wound/incision care IV therapy
Infection control measures Complications to report Physician follow up
Home safety Oxygen safety Diet
Elevating legs to decrease edema Off loading techniques Sharps disposal
Plan of care review Medication management Inability to void post foley removal
Discharge instructions
Aseptic technique Sterile technique Cleansed with NS
Gauze ABD pad Telfa Packed
Wet to dry-NS Secured with tape/ace wrap/stockinette Wound vac applied with Black
White Silver foam Canister changed Constant suction
Intermittent suction Pressure Approx. drainage in canister

IV Therapy

NS Before After meds/blood draw Final flush with Heparin
alcohol betadine chloraprep line dressing changed on using sterile technique alcohol swabs
3 provodine swabs chloraprep swab antimicrobial patch Applied Occlusive dressing
Gauze dressing Extension set Injection site Site free of complications
Flushes easily Good blood return Line removed (type) Length
Tip intact Pressure dressing applied
Foley catheter inserted Leg bag Bedside drainage bag
Foley removed without incident Instructions given regarding complications to report Bowel program performed
See communication sheet for addendum notes
Patient tolerated interventions well Patient /CG verbalized/demonstrated understanding of instructions provided reason for visit independent with
Wound care IV therapy
Medication management Wound/ incision healing without complications
Tolerating medications without side effects or adverse reactions atient will follow with physician as instructed
Discharge/no other nursing visits needed/ordered Other
Physical limitations Learning limitations Refuses to learn N/A Pt/CG are independent


I certify that the RX Team Home Health Care LLC Employee listed on this note worked the times indicated and the work was performed in a satisfactory manner.

I agree to the times regarding this slip.