Visit

<aside> ❤️

Vitals

• Heart rate
• Blood pressure
• Temperature
• O2 sat / oxygen use
• Respiration
• Height / weight </aside>

<aside> ⏱️

History

• Vaccines: flu, shingles, pneumonia, Covid
• Allergies
• Advanced directives: DNR, living will, POA </aside>

<aside> 🏠

Living environment

• Where does patient live?
• Friends, family, paid caregivers
• Stairs, clutter, pets, hazards
• DME in the home </aside>

<aside> 🧠

Mental status

BIMS

• What year is it?
• What month is it?
• What day is it?
• Repeat sock / blue / bed
• Recall sock / blue / bed

PHQ-2 - Over the last 2 weeks, how often have you felt:

• Little interest or pleasure in doing things?
• Feeling down, depressed or hopeless? </aside>

<aside> 🩲

Bladder & bowel

• Last bowel movement
• Bladder / bowel incontinence
• UTI in the past 14 days? </aside>

<aside> 🤕

Pain assessment

• Pain intensity (with and without meds)
• Pain location
• Duration/quality/what makes pain better or worse </aside>

Debrief

<aside> ✅

Introduction

• Race & ethnicity
• Focus of care
• Goals
• Frequencies and other disciplines
• Recent falls, ER visits, hospitalizations </aside>

<aside> 🧑‍🦽

ADLs

• Prior ability: ambulating, stairs, grooming, cognition
• Bed mobility
• Transfer ability
• Ambulation / wheelchair
• Upper body </aside>

<aside> ⌛

Mental status (continued)

• Alert and oriented
• Substance abuse
• Noncompliance with instruction </aside>

<aside> 🩹

Wounds

• Locate the wound!
• Wound size
• Wound description: etiology, drainage, odor, appearance
• Wound care (can say “same as previous wound” if multiple)
• Wound care frequency </aside>