Nursing Clinical Note Form
Encounter Type
Scheduled visit
PRN visit
Extra visit
Other
Purpose of Visit
Diagnosis/Chief Complaint:
Clinical Findings
B/P:
/
Right
Left
Pulse:
Blood Sugar:
Date of last doctor's visit:
Respiration:
Temperature:
Weight:
O₂ Sat:
on room air
O₂
Pain Assessment
Is patient experiencing pain?
Yes
No
Pain Level:
On pain meds?
Yes
No
Location:
Description:
Aching
Nagging
Dull
Heavy
Crushing
Sharp
Radiating
Burning
Tingling
Cramping
Other
Medication:
Effective:
Yes
Partially
No
Duration of effectiveness:
Min
Hour
Skilled Observation/Assessment
Neuro/Mental:
No Deficit
A/O
Forgetful
Confused
Disoriented
Agitated
Depressed
Non-suicidal
Lethargic
Comatose
Other
Cardiovascular:
No Deficit
Angina (1-10)
Palpitation
Heart/Pulse
Murmur
Pedal pulse
Pacemaker
Cap refill
Cyanosis
Pale
SOB
SOBOE
JVD
Fatigue
Pedal edema +
Pitting edema +
Location
Orthostatic
Hypotension
Syncope
Dizziness
Other
Respiratory:
No Deficit
Clear
Wheeze
Rales
Rhonchi
Shallow
Diminished
Orthopnea
Congested
Cold/Flu
O2
Lpm
Cont
PRN
HHN
Other
Gastrointestinal:
No Deficit
Bowel sounds
N/V
Abdominal pain
Constipation
Diarrhea
Last BM Date
Bowel incontinent
Colostomy
Other
Musculoskeletal:
No Deficit
Weakness
Unsteady gait
Limited mobility/ROM
Inflammation
Paralysis
Contracture
Fracture
Amputation
Bed-bound
Chair-bound
Cane
Walker
W/C
Other
IM/SC/IV Order:
Medication
Site of injection
Other assessment
Skilled Services Narrative
Analysis/Observation & Assessment/Intervention/Instructions/Patient/PCG Response:
Progress Towards Goals
Progress:
Decreased endurance
SOBOE
Non-wt bearing
Needs help with all ADL/IADL
AMB
ft then must rest
Other reason(s)
Patient/Caregiver Teaching/Instruction
Medication:
Coordination of Care/Care Planning:
Discussed with MD
Discussed with Patient/PCG
Discussed with Agency
MD contact/order
Disease Process:
Procedure:
Care coordination/Conference/Referrals:
Patient/PCG unable to manage skilled care due to:
Patient/Caregiver Response:
Demonstrated/verbalized
Complete understanding
Partial understanding
Unable to understand/demonstrate
Handout provided
More teaching required
Other
Homebound
Decreased endurance
SOBOE
Non-wt bearing
Needs help with all ADL/IADL
AMB
ft then must rest
Other reason(s)
Patient Name:
SN Name/Title:
Submit