Patient ID: @NAME@

Age: @AGE@. (DOB: @DOB@)

@RACE@

Gender: @SEX@

HOME VISIT

Chief Complaint: @CC@

@M@ @NAME@ is a @AGE@ who is seen at his/her personal home (not a nursing facility) because *** patient is homebound (requires considerable effort and/or assistance to leave the home, so seldom does) *** and patient/family member/member of the home health team requests a house call *** and physician needs to negotiate care or clinical decision making with patient and caregivers *** and physician needs to assess home environment, and patient and caregiver function.

The home visit is requested by: ***

Last admission: ***

Impairments/immobility

Evidence of cognitive impairment? {yes no:314532}

Demonstrated advanced activities of daily living (check all that apply):

- Employment/volunteering {YES NO WND:2056}

- Reading {YES NO WND:2056}

- Music {YES NO WND:2056}

- Hobbies {YES NO WND:2056}

- Socialization {YES NO WND:2056}

- Other ***

Instrumental ADL's: (Independent/Assisted/Dependent)

Use telephone ***

Shopping ***

Food preparation ***

Housekeeping/Laundry ***

Using transportation ***

Managing medications ***

Managing money ***

Physical ADL's: (Independent/Assisted/Dependent)

Bathing ***

Dressing ***

Grooming ***

Eating ***

Transferring ***

Continence ***

Toileting ***

Sensory impairments:

- Vision {YES NO WND:2056}

- Hearing {YES NO WND:2056}

Any falls in the last 6 months? {YES NO WND:2056}

Nutritional status

Eating habits: ***

Variety and quality of foods: ***

Nutritional status: ***

Alcohol presence/use: ***

Fluid intake: ***

Swallowing difficulty: ***

Oral health: ***

Home environment:

Neighborhood safety: ***

Other occupants of home: ***

Pets present: {YES NO WND:2056}

Cleanliness: ***

Hall spaces: ***

Safety:

Assistive mobility device needed: {YES NO WND:2056}

Mobility device easily accessible: {YES NO WND:2056}

Telephone available: {YES NO WND:2056}

Fire and smoke detectors: {YES NO WND:2056}

Loose rugs present: {YES NO WND:2056}

Loose electrical cord hazards: {YES NO WND:2056}

Stairs present: {YES NO WND:2056}

Railings on stairs: {Responses; yes/no/not indicated:16556}

Raised toilet seat: {YES NO WND:2056}

Nonslip surface in tub/shower? {YES NO WND:2056}

Handholds in tub/shower? {YES NO WND:2056}

Handholds around toilet? {YES NO WND:2056}

Firearms present in home: {YES NO WND:2056}

If yes, are they secured?: {Responses; yes/no/not indicated:16556}

Is lighting present and sufficient?: {YES NO WND:2056}

Current services utilized: ***

@PMH@

@ALLERGY@

Meds: Reviewed

Pill bottles appropriate: {YES NO WND:2056}

System used for medications: ***

@MED@

@FAMHX@

@SOC@

Code Status: @RRCODESTATUS@

Advanced Directives: -@FLOW(400010:last)@

Type of Directive: @FLOW(4126:last)@. In chart under media? {yes no:314532}

POA Name: @FLOW(5081:last)@

Healthcare Agent Name: @FLOW(400050:last)@

Primary Caregiver:

@FLOW(364040:last)@

Review of Systems:

@ROS@

Objective:

@VS@

@PHYEXAMBYAGE@

PHQ2: ***

GDS: ***

@LABS24@

Assessment:

@DIAGREFRESH@

Plan:

@PROBEDITWNOTE@

@FOLLOWUP@

Home health needs: ***

Referrals made: ***

Total time of visit: *** 15 25 40 60 minutes

More than 50% of this face-to-face visit time was spent providing counseling and coordinating the patient's care.

@ME@