Skilled Nursing Visit Note

Vital Signs*

Musculoskeletal*

WNLAmbulatesNeeds AssistUnsteady gateSelf-care deficitLimited ROM/Mobility
Muscles*

NormalWeak
Urinary*

WNLIncontinenceFrequency
Foley Cath:

IntactLeaking
Retention

NoYes: Level
S/S UTI

NoYes:
Pain*

YesNo
Pain intensity (0-10) blanks Location blank .
Type of Pain

ContinuousIntermitent
Pain Intensity (0-10) blanks Location: blank .
Pain Alleviated by:
Pych:*

No Stated ProblemsMore Options
Select all that apply:

AgitatedAnxiousDepressedSleep DisturbancesSuicidalOther
Current Intravenous status*

Not ApplicableYes
Was new IV administered?*

YesNo
I.V. Site:

Within Normal LimitsTender / PainfulRednessEdemaDrainageSutures
Current Dressing:

Dry and IntactDressing changedTubing changedInjection cap changedFilter changed/addedSwab cap changedType of Dressing:
I.V. Access:

PeripheralPICCPortCVLOther
I.V. Purpose

HydrationMedsChemoPain ManagementTPN / LipidsOther
Pump:*

YesNo
Pump:*

GravityIV Push
Pump Type blanks* Settings:blank* .

IV Flushing

Normal SalineHeparin
Normal Saline ml
Normal Saline

before med and prnafter med and prn
Heparin:

10 units/ml100 units/ml
Heparin ml after normal saline
Skilled Nurse Action:*

Direct care providedAssessed/EvaluatedDemonstratedInstructedObserved
Describe nurse action given and provide next scheduled visit date*
Is there another infusion visit required?*

YesNo
Next planned visit*

MonthDayYear
Date
Client Response:*

Tolerated with no changesVerbalizes UnderstandingReturn DemonstrationNeeds ReinforcementUnable to learn
Client limitations:
Nurse Name*

First NameLast Name
Nurse Email*
example@example.com
Nurse Signature*

Clear
Date*

MonthDayYear
Date
Client/PCG Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: