Vital sign ranges

B/P:

T:

P:

R:

Blood sugar:

Wgt (in lbs.):

Skin

Skin condition: Intact. Not intact - add site, measurement, drainage, and amount below.

Wound status
 and measurements

 In Use

 Compliant

 In Use

 Compliant

Homebound status

 Unable to ambulate

 Unsteady gait/balance

 Requires assist of 1-2 people

 Requires assistive device

 Bed bound

 Chair bound

 Uncontrolled pain

 Difficult and taxing effort to leave home

 Unable to walk without severe weakness

 Not homebound as able to leave home without difficulty or leaves on a frequent basis

Documentation of difficult and taxing effort to leave home

Injury/illness:

Current condition:

Health status:

Patient specifics:

Caregiver information

Availability: Available. No one available. Limited.

Primary caregiver:

Hospitalizations and falls

ER visits or hospitalizations:

Reasons for each ER visit
 and hospitalization:

Falls:

Description of each
 fall incident:

Review of systems

Cardiac:

Respiratory:

Community resources

Resources:

Progress toward goals

Progress:

Education needed

Education:

Visit frequency

Frequency:

Social concerns

Notes:

“What matters to me” - the patient

at this moment:

as a result of this support:

good day: