Nurses Direct, LLC
109 South College Rd - Lafayette, LA 70503
Nurse's Name
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First Name
Last Name
Employee personal email
*
example@example.com
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RN
LPN
CNA
Are you on Home health or Hospice contract assignment?
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YES
NO
Home Health / Hospice shift worked:
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St. Joseph Hospice
Heart of Hospice
Elara Caring
Private Duty
Touro HH
Other
HOH Location:
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BR Region (Baton Rouge, LA)
Acadiana Region (Lafayette, LA)
Southwest Region (Lake Charles, LA)
Northeast Region (Monroe, LA)
Northwest Region (Olive Branch, MS)
NOLA Home (Gretna, LA)
Northshore Region (Covington, LA)
Central Region (Shreveport, LA)
Southern Region (Hattiesburg, MS)
Bayou Region (Franklin, LA)
Delta Region (Clevland, MS)
Halcyon (Batesville, MS)
Halcyon (Belden, MS)
Columbia Region (Comumbia, SC)
Halcyon (Philadelphia, MS)
Halcyon Villa Rica
Elara Caring Location:
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Alexandria
Marksville
Metairie
Baton Rouge
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Home visit
Office Meeting
Weekday On Call
Weekend On Call
Date worked:
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-
Month
-
Day
Year
Date
Home Visit #1:
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Admit
Death / Discharge
Routine / Office Visit
Recertification
Resumption of care
Patient not home
ON CALL - ADMIT
ON CALL - DEATH / DISCHARGE
ON CALL - ROUTINE
ON CALL - RECERTIFICATION
ON CALL - RESUMPTION OF CARE
ON CALL - PATIENT NOT HOME
COVID + (Patient or anyone living in home)
WEEKDAY ON-Call (no visit seen)
WEEKEND ON-Call (no visit seen)
Patient #1 Name
First Name
Last Name
Home Visit #2:
Admit
Death / Discharge
Routine / Office Visit
Recertification
Resumption of care
Patient not home
ON CALL - ADMIT
ON CALL - DEATH / DISCHARGE
ON CALL - ROUTINE
ON CALL - RECERTIFICATION
ON CALL - RESUMPTION OF CARE
ON CALL - PATIENT NOT HOME
COVID + (Patient or anyone living in home)
Patient #2 Name
First Name
Last Name
Home Visit #3:
Admit
Death / Discharge
Routine / Office Visit
Recertification
Resumption of care
Patient not home
ON CALL - ADMIT
ON CALL - DEATH / DISCHARGE
ON CALL - ROUTINE
ON CALL - RECERTIFICATION
ON CALL - RESUMPTION OF CARE
ON CALL - PATIENT NOT HOME
COVID + (Patient or anyone living in home)
Patient #3 Name
First Name
Last Name
Home Visit #4:
Admit
Death / Discharge
Routine / Office Visit
Recertification
Resumption of care
Patient not home
ON CALL - ADMIT
ON CALL - DEATH / DISCHARGE
ON CALL - ROUTINE
ON CALL - RECERTIFICATION
ON CALL - RESUMPTION OF CARE
ON CALL - PATIENT NOT HOME
COVID + (Patient or anyone living in home)
Patient #4 Name
First Name
Last Name
Home Visit #5:
Admit
Death / Discharge
Routine / Office Visit
Recertification
Resumption of care
Patient not home
ON CALL - ADMIT
ON CALL - DEATH / DISCHARGE
ON CALL - ROUTINE
ON CALL - RECERTIFICATION
ON CALL - RESUMPTION OF CARE
ON CALL - PATIENT NOT HOME
COVID + (Patient or anyone living in home)
Patient #5 Name
First Name
Last Name
Home Visit #6:
Admit
Death / Discharge
Routine / Office Visit
Recertification
Resumption of care
Patient not home
ON CALL - ADMIT
ON CALL - DEATH / DISCHARGE
ON CALL - ROUTINE
ON CALL - RECERTIFICATION
ON CALL - RESUMPTION OF CARE
ON CALL - PATIENT NOT HOME
COVID + (Patient or anyone living in home)
Patient #6 Name
First Name
Last Name
Home Visit #7:
Admit
Death / Discharge
Routine / Office Visit
Recertification
Resumption of care
Patient not home
ON CALL - ADMIT
ON CALL - DEATH / DISCHARGE
ON CALL - ROUTINE
ON CALL - RECERTIFICATION
ON CALL - RESUMPTION OF CARE
ON CALL - PATIENT NOT HOME
COVID + (Patient or anyone living in home)
Patient #7 Name
First Name
Last Name
Home Visit #8:
Admit
Death / Discharge
Routine / Office Visit
Recertification
Resumption of care
Patient not home
ON CALL - ADMIT
ON CALL - DEATH / DISCHARGE
ON CALL - ROUTINE
ON CALL - RECERTIFICATION
ON CALL - RESUMPTION OF CARE
ON CALL - PATIENT NOT HOME
COVID + (Patient or anyone living in home)
Patient #8 Name
First Name
Last Name
Home Visit #9:
Admit
Death / Discharge
Routine / Office Visit
Recertification
Resumption of care
Patient not home
ON CALL - ADMIT
ON CALL - DEATH / DISCHARGE
ON CALL - ROUTINE
ON CALL - RECERTIFICATION
ON CALL - RESUMPTION OF CARE
ON CALL - PATIENT NOT HOME
COVID + (Patient or anyone living in home)
Patient #9 Name
First Name
Last Name
Home Visit #10:
Admit
Death / Discharge
Routine / Office Visit
Recertification
Resumption of care
Patient not home
ON CALL - ADMIT
ON CALL - DEATH / DISCHARGE
ON CALL - ROUTINE
ON CALL - RECERTIFICATION
ON CALL - RESUMPTION OF CARE
ON CALL - PATIENT NOT HOME
COVID + (Patient or anyone living in home)
Patient #10 Name
First Name
Last Name
Home Visit #11:
Admit
Death / Discharge
Routine / Office Visit
Recertification
Resumption of care
Patient not home
ON CALL - ADMIT
ON CALL - DEATH / DISCHARGE
ON CALL - ROUTINE
ON CALL - RECERTIFICATION
ON CALL - RESUMPTION OF CARE
ON CALL - PATIENT NOT HOME
COVID + (Patient or anyone living in home)
Patient #11 Name
First Name
Last Name
Home Visit #12:
Admit
Death / Discharge
Routine / Office Visit
Recertification
Resumption of care
Patient not home
ON CALL - ADMIT
ON CALL - DEATH / DISCHARGE
ON CALL - ROUTINE
ON CALL - RECERTIFICATION
ON CALL - RESUMPTION OF CARE
ON CALL - PATIENT NOT HOME
COVID + (Patient or anyone living in home)
Patient #12 Name
First Name
Last Name
List Names of all patients seen today:
List Total miles driven today
*
Miles driven from each home to home. Or from office to first home and last home to Office.
Care Provided
*
Please list care provided for patient during home visit.
Time During Home Visit
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Minutes
Until
until
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Minutes
I understand that ALL charting for ALL patients seen on this date of service should be completed prior to being paid for any work done on this date of service. ALL patient charting should be completed within 24 hours.
*
YES
Nurses Direct Staff Signature
*
Submit
Should be Empty: