Comprehensive Supervisory Assessment
Emeritus Home Care
Nurse Email (DO NOT EDIT)
example@example.com
Client Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Gender
*
Please Select
Male
Female
Marital Status
*
Please Select
Single
Married
Separated
Divorced
Widowed
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medicaid ID
*
Payer Source
*
Please Select
CCSP
SOURCE
Private Pay
Medical Diagnosis
*
Approved Hours Per Day
*
Approved Days Per Week
*
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Vitals
Temperature (°F)
*
Respiration
*
Systolic
*
Diastolic
*
Pulse
*
Height (feet)
*
Please Select
3'5"
3'6"
3'7"
3'8"
3'9"
3'10"
3'11"
4'0"
4'1"
4'2"
4'3"
4'4"
4'5"
4'6"
4'7"
4'8"
4'9"
4'10"
4'11"
5'0"
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
5'9"
5'10"
5'11"
6'0"
6'1"
6'2"
6'3"
6'4"
6'5"
6'6"
6'7"
6'8"
6'9"
6'10"
6'11"
7'0"
7'1"
7'2"
7'3"
7'4"
7'5"
7'6"
7'7"
Weight (lbs)
*
Was there recent weight gain?
*
Yes
No
Was there recent weight loss?
*
Yes
No
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Assistive Devices
Select All That Apply
*
Walker
Cane
Wheelchair
Oxygen
Hospital Bed
Hoyer Machine
Apnea Machine
Concentrator
Glasses
Dentures
Commode
Nebulizer
Crutches
Hearing Aide
ERS Monitoring Device
None
Other
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Diet
Select All That Apply
*
Regular Diet
Diabetic Diet
Low Sodium Diet
Tube Feeding
Soft Diet
High Fiber Diet
Low Fiber Diet
Cardiac Diet
Liquid Diet
Vegetarian/Vegan Diet
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Allergies
Select All That Apply
*
None Known Allergies
Seasonal Allergies
Pet Allergies
Food Allergies
Medication Allergies
If any allergies, please list:
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Physical Review
Were any new medical conditions or significant changes in the client's health status identified?
*
No
Yes, please explain
Were there any visible skin issues or changes noted?
*
No
Yes, please explain
Were there any changes or concerns with the client’s functional ability or mobility?
*
No
Yes, please explain
Were there any changes or safety concerns noted in the home environment?
*
No
Yes, please explain
Were there any changes or issues related to medication?
*
No
Yes, please explain
Has the client experienced any hospitalizations or emergency room visits since the last visit?
*
No
Yes, please state when and what happened
Has the client experienced any recent falls, accidents, or injuries?
*
No
Yes, please state when and what happened
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Physical Findings
Please mark all findings on the body chart with a number and describe in the textbox below. If there are no findings, please put "None" in the textbox.
1. Abnormal Color
8. Lesions
2. Body Piercing
9. Rashes
3. Bruises
10. Scars
4. Decubitus
11. Skin Tear
5. Dryness
12. Tattoos
6. Inciscions
13. Other (List Below)
7. Lacerations
Describe and mark all findings on body chart using the number references above.
Please describe all findings. If there are no findings, please put "None" in the textbox.
*
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Service Review
Has the client shown progress in their condition or overall well-being since the last visit?
*
Yes
No, please explain
Were there any issues or concerns reported by the client or observed during service delivery?
*
Yes
No
Is the client satisfied with the quality of care and services provided by the staff?
*
Yes
No, please explain
Are staff members delivering care that is consistent with the client's care plan and level of need?
*
Yes
No, please explain
Did the client or representative express any new complaints or concerns?
*
No
Yes, please explain
Are assigned staff members competent and appropriately trained to meet the client's needs?
*
Yes
No, please explain
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Care Plan Review
Was the client’s care plan reviewed during this visit?
*
Yes
No
Is the current care plan accurate, up to date, and aligned with the client’s current condition?
*
Yes
No
Does the care plan need to be modified?
*
Yes
No
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Medication Profile
Please review and update the client's medications. If there are no new changes, write 'no new changes,' and we will manually sync it with the last visit's medication list. If there are any new medications, be sure to add them.
Medications
*
Medication Name
Dosage
Form
Frequency
Medication Usage
Notes
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
Nurse Name
*
First Name
Last Name
Date of Review
*
/
Month
/
Day
Year
Date
Nurse Signature
*
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Task Sheet Review
Please review and verify that the tasks listed on the client's task sheet are accurate. If changes are needed, please updated accordingly.
Client Name
*
First Name
Last Name
Companionship Task Sheet
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Grocery Shopping
Light Housekeeping
Transportation to Doctor
Community Integrations
Meal Preparations
Feeding
Laundry
Empty Trash
Personal Care Task Sheet
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Dressing/Grooming
Ambulation/Mobility
Transfers
Toileting Assistance
Diaper Changes
Vital Changes
Cut Nails (Non-Diabetic)
Oral Hygiene
Hair Care
Bath/Shower
Apply Lotion
Skilled Nursing Task Sheet
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Medication Management
Bowel Program
Wound Care/Ostomy Management
Urine Catheter
Tube Feeding
Insulin Injections
Vital Sign Management
Decubitus/Ulcers or Skin Disorder Management
Patient Education Services
Pain Management
Are the tasks on the client's task sheet accurate?
*
Yes, the task sheet is accurate. No changes are needed.
No, the task sheet was updated.
Nurse Name
*
First Name
Last Name
Date of Review
*
/
Month
/
Day
Year
Date
Signature
*
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Updates and Changes
Are there any updates or changes related to the member's services that they are currently receiving? (These are updates and changes related only to the services Emeritus Home Care is providing)
*
No
Yes, there were changes to the service duration (please elaborate)
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Comprehensive Summary of Visit
Please describe in detail of your visit:
*
Nurse Name
*
First Name
Last Name
Date
*
/
Month
/
Day
Year
Date
Nurse Signature
*
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Submit
Should be Empty: