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001002 PILOT (1/01)
To reorder call 924-5681
Copy 1: OFFICE CHART Copy 2: NURSING HOME
NURSING HOME PROGRESS NOTE
PATIENT NAME
MR#
ADDRESSOGRAPH
Date: o Initial Visit o Acute Care o Recertification o Annual Exam
Ambulation
o Nonambulatory o With Cane o Unassisted
o With Assistance o With walker
Continence Continent Incontinent
Urine oo
Bowel oo
FUNCTIONAL STATUS
Basic ADLs Indep. Needs Asst. Dep.
Transfers ooo
Feeding ooo
Bathing ooo
Dressing ooo
Grooming ooo
PHYSICAL EXAM / CLINICAL DATA T _______ P_______ BP_______/_______ Wt:
o GT o Urinary Catheter o Trach o O2
Other
GENERAL APPEARANCE
HEENT o EOM Intact o Eyes Clear o No erythema, exudate or leison o TM intact o Good dentition Other
NECK o Neck symmetrical, no masses, trachea midline o Thyroid not enlarged, non-tender Other
CARDIOVASCULAR o RRR o Normal S
1
& S
2
o S
3
o S
4
o No murmur
RESPIRATORY o Bilaterally clear to auscultation
GI o Soft, non-tender o Bowel sounds present o No Mass o No Organomegaly
EXTREMITIES o No cyanosis, clubbing or edema
NEURO o A&O X 3 o CN Intact o Motor 5/5 o Sensations Intact o Reflexes normal/symmetric Gait
SKIN
OTHER
LAB
o Total Care Plan/Pharmacy/Medication Orders Reviewed o Labs Reviewed o Radiology Reviewed
ASSESSMENT & PLAN
Continues to need nursing facility care for
NP/Resident’s Signature Date
o I saw and examined the patient. I agree with/revise ’s history, exam and assessment and plan.
Attending Signature Date
Advance Directives o Yes o No
Allergies
Problem List: o Reviewed o Updated
HISTORY:
History obtained from: o Patient o Family
o Nursing Staff o Chart o Therapy Staff
PMHx:
Social/Family Hx
HPI: CC: Recent problems ROS: Constitutional o neg
Eyes o neg
ENT, Mouth o neg
Respiratory o neg
Cardiovascular o neg
GI o neg
GU o neg
Neuro o neg
MS o neg
Psych o neg
Other
MEDICATIONS: o Reviewed
Recent Changes