All Care ALF Visit Note

ALF Visit Note
Home Health or Hospice?*

Home HealthHospice
Patient First and Last Name Should Match Name in EHR
Patient First Name*
Patient Last Name*
Please Double Check Spelling Prior to Submission
Actual Visit Date*

MonthDayYear
Date
Community Name (Please Ensure This is Correct)*
If Missed Visit is Marked "Yes", Narrative will Read: "Missed Visit, will attempt to re-schedule for current week if applicable". If this narrative does not fit, please choose no and add applicable description to narrative.
Is This Visit a Missed Visit?

YesNo
Were Vitals Taken?

YesNo
Blood Pressure*
example, if # is 65, use zero... 120/065
Temp:*
O2 Sat:*
Heart Rate:*
Resp Rate:*
Pain ____ / 10:*
Select Yes or No (Required)
Abnormal Vital Signs (If "Yes", what interventions were put in place?)*

YesNo
Plan of Care Followed? (If "No" or changes made to POC, elaborate in Narrative)*

YesNo
Medication Changes Made? (If "Yes", elaborate in Narrative)*

YesNo
New Issues Identified? (If "Yes", elaborate in Narrative)*

YesNo
Complete Face-to-Face Check-In with Facility Leadership?*

YesNo
Additional Questions, Select Yes, No or NA (Required)
Wound Care Provided per POC?*

YesNoNot Applicable
Adequate Supplies on Hand?*

YesNoNot Applicable
Education on How To Care for Patient - Completed?*

YesNoNot Applicable
Aide Narrative Examples:
- All aid cares performed as care planned, no issues identified. Updated _(name)_ CM and facility staff __(name)__. Continue with current care plan.
- Patient declined (hair wash/Shower); all other aid cares performed as care planned. No other issues identified. Updated _(name)_ CM and facility staff __(name)__. Continue with current care plan.
- Patient declined all aid cares, no other issues identified. Updated _(name)_ CM and facility staff __(name)__. Continue with current care plan.
- Patient given bed bath, per case manager instructions. All other aid cares performed as care planned. No other issues identified. Updated _(name)_ CM and facility staff __(name)__. Continue with current care plan.
Volunteer Example:
- Seen for Volunteer Services. Care planned followed.
Narrative Note: (Details, if Indicated Above):*

0/3000
Clinician Electronic Signature (Required)
Staff First and Last Name*
Staff Title (RN, PT, CNA, OT, Chaplain, Volunteer, etc)*
Staff Email Address(Verify Spelling and @myallcare.net) Note Confirmation Will Be Sent to This Address:*
first.last@myallcare.net
BEFORE YOU SUBMIT! PLEASE DOUBLE CHECK THAT THE PATIENT'S NAME, YOUR FIRST AND LAST NAME AND VISIT DATES ARE CORRECT. THIS IS A MEDICAL RECORD AND MUST BE ACCURATE.
Should be Empty:

ALF Visit Note

Patient First and Last Name Should Match Name in EHR

Please Double Check Spelling Prior to Submission

If Missed Visit is Marked "Yes", Narrative will Read: "Missed Visit, will attempt to re-schedule for current week if applicable". If this narrative does not fit, please choose no and add applicable description to narrative.

Select Yes or No (Required)

Additional Questions, Select Yes, No or NA (Required)

Clinician Electronic Signature (Required)

BEFORE YOU SUBMIT! PLEASE DOUBLE CHECK THAT THE PATIENT'S NAME, YOUR FIRST AND LAST NAME AND VISIT DATES ARE CORRECT. THIS IS A MEDICAL RECORD AND MUST BE ACCURATE.