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Jeannie Wallace
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Demographics
Patient Name:
Visit Date:
HHA Frequency:
Diet:
Allergies:
Vital Sign Parameters
N/A
SBP:
DBP:
HR:
Resp:
Temp:
Weight:
Safety Precautions
Anticoagulant Precautions
Emergency Plan Developed
Fall Precautions
Keep Pathway Clear
Keep Side Rails Up
Neutropenic Precautions
Proper Position During Meals
Safety in ADLs
Sharps Safety
O2 Precautions
Seizure Precautions
Slow Position Change
Standard Precautions
Support During Transfer
Use of Assistive Devices
Other:
Plan Details
Vital Signs
QV
QW
N/A
Temperature
Blood Pressure
Heart Rate
Respirations
Weight
Personal Care
QV
QW
N/A
Bed Bath
Assist with Chair Bath
Tub Bath
Shower w/Chair
Shampoo Hair
Hair Care/Comb Hair
Oral Care
Skin Care
Nail Care
Shave
Assist with Dressing
Medication Reminder
Functional Limitations
Ambulation
Bowel/Bladder Incontinence
Contracture
Hearing
Paralysis
Endurance
Amputation
Speech
Legally Blind
Dyspnea with Minimal Extertion
Other:
Comments / Additional Instructions
Notifications
Reviewed with Home Health Aide
Patient oriented with Care Plan
Date:
RN Signature:
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