FIRST HOME VISIT. What barriers do you feel you may have in following these instructions?

FIRST HOME VISIT

Clinical Assessment

Self Management Teaching with

Patient/Caregiver

Communication/

Collaboration

Documentation

Vital signs: Complete baseline vitals.

BP: take in both arms. Arm should be supported and not dependent. Determine which arm has higher reading. This is the arm to use for BP in the future.

Using that arm, take BP in the sit/stand mode or supine/ sit mode.

Pulses: both apical and radial with deficits noted. Respiratory Assessment:

• Lung auscultation: Assess all lung fields for crackles, wheezes, rhonchi.

• Dyspnea: Assess level of dyspnea at rest and with activ-ity.

•Cough and Orthopnea: Assess

• Chest pain: Assess any episodes of chest pain and ac-tions taken.

Edema: Assess/document bilateral ankle and calf (con-sistent 20 cms. above ankle bone mark) measurements in cms.

Weights: Weigh patient and teaching includes the im-portance of daily consistent time weight taking and log-ging. Refer to Page 27CFYH. Assess patient’s ability to use scale and document correct weight. TARGET weight: round up i.e. 150.3 = 151. 180.2 = 181. Document Target Weight in pts. copy of CFYH.

Medications: Assess evidence of medication side effects and/or electrolyte imbalance. Assess patient adherence to ordered medications and any barriers identified. ADLs/IADLs: Assess patient’s ability to manage A.D.L.s, available caregiver support. Assess whether pt. would benefit from Rehab services for energy conservation as-sessment and teaching, Home Exercise Program, etc.

Assess patient/caregiver knowledge of

Caring for Your Heart: Living Well with Heart Failure (CFYH) book. Page 1 “Tell me what you know about

Heart Failure1”

Begin Self Management teach-ing/discussion using Page 2.

“What barriers do you feel you may have in following these instruc-tions?”

Medication Reconciliation:

• Assess patient’s knowledge re meds • Teach at least 2 high risk medications

including one diuretic (Page 7 CFYH). • Use Pages 3-8 CFYH as teaching tools w/patient. Have them think about & write in idea log on Page 8.

• For patients on ACE Inhibitors instruct not to use salt substitutes because they have high levels of Potassium, and ACE inhibitors retain Potassium.

CFYH General:

• Introduce Page 22, Daily Check-Up • Review Page 29, When Should I Call • Encourage pt/caregiver to read,

re-view Pages 23-30 and write down ideas and/or questions on Page 30. As always with initial visits, confirm the patient/ caregiver has the correct phone numbers to contact you and the hospital and understands how to triage/who to call with questions.

Goals of program - inform pt/cg of goals:

• Avoid rehospitalizations • Independent disease

man-agement. DC Planning:

• Discuss MD ordered visit frequency 3w1,2w1,1w2. Set up next visit .

Reports:

• If no scale in home, speak to your A.D.N. and develop plan to obtain one.2 _{Report case} open to A.D.N.

• Provide report to CARE MAN-AGEMENT (CM)3 nurse on all cases, whether CM patient or not4_.

• Call ordering MD reporting case open, clinical findings outside parameters, medica-tion discrepancies. Request verbal orders for needed supplies/services/ disciplines • For inpatient discharges: If no cardiology appointment set up 7 days after hospital d/c, call Jenny (Yevgenia Tarta-kovsky ) at 212 423 -8456. • For Cardiology Clinic referrals,

ensure Medical Clinic appt has been set up within 30 days.

OASIS:

Complete with all docu-ments in admission pack-et as appropriate. I.O.:

After obtaining Verbal Orders from MD, write Interim Orders for any changes to the Plan of Care.

Managed Care Report: Complete managed care report if needed. Teaching:

Document all teaching specifically using page numbers in CFYH booklet. Med teaching includes names of medications. Self Management: Documentation includes patient/ caregiver ability to self manage, any bar-riers identified,

knowledge deficits, and all teaching planned for next visit.

1 _{Questions in this font are ideas on how to begin visit. Use as appropriate} 2_{Refer to Protocol for Obtaining Scale}

SECOND HOME VISIT

Clinical Assessment

Self Management Teaching with Patient/

Caregiver

Communication

/Collaboration

Documentation

Perform comprehensive assessment including: Vital signs: Complete baseline vitals.

BP: Take in arm identified in prior visit. Using that arm, take BP in the sit/stand mode or supine/ sit mode.

Pulses: both apical and radial with deficits noted.

Respiratory Assessment:

• Lung auscultation: Assess all lung fields for crackles, wheezes, rhonchi.

• Dyspnea: Assess level of dyspnea at rest and with activity.

• Cough and Orthopnea: Assess

• Chest pain: Assess any episodes of chest pain and actions taken.

Edema: Assess/document bilateral ankle and calf (consistent 20 cms. above ankle bone mark)

measurements in cms.

Weights:

• Review Weight Log on last page of CFYH. Observe patient weighing self.

• All subsequent weights are now rounded

down, i.e., 150.3 = 150. 180.8 = 180.

• Refer to Page 29. If patient’s weight is up 4 pounds or more from Target Weight, Medical Clinic is called. 212 423 7000. Identify self as HF patient and request immediate appt. Medications: Assess medication compliance, any evidence of medication side effects and/or electrolyte imbalance. Assess patient adher-ence to ordered meds, identify barriers to compliance.

Ask patient/caregiver how they are doing and if they have any questions.

“How are you feeling today? What would you like to discuss regarding your heart health to-day?5”

Daily Check up CFYH:

• Assess patient/caregiver’s use pp 22-30 CFYH.

• Review Page 30, ideas and questions. Ask patient for teach back on Pages 22-28 CFYH.

• Identify and address any barriers.

• If patient/ caregiver has experienced any symp-toms described on those pages, listen, assess and teach. Contact MD if clinically indicated.

Medications:

• Ask to see all medication bottles and ask patient for teach back regarding meds taught at prior vis-it. Reinstruct as needed.

• Review pp 3-7 CFYH.

• Review pt/caregiver writing on Page 8 CFYH.

• Teach at least two more medications, if patient is taking more medications.

Nutrition:

• Introduce concept of dietary intake on pps. 9-16

CFYH.

• If possible, use foods in home as teaching tools

with CFYH, especially pages 14 and 15, which have Food Labels.

• Ask patient to provide a 24 hour dietary recall. Review Page 16 with patient to identify small changes they are willing to make.

Emergency Instructions:

Reiterate instructions on page 29 CFYH AND “When to Come to ER or call 911, “ on page after page 30 of

CFYH.

-If CARE MANAGE-MENT6 _{patient and} equipment has been delivered, ask pa-tient/ caregiver to demonstrate use of equipment. -Collaboration CARE MANAGEMENT: Contact CM nurse at least weekly (Mon. preferred) whether CM patient or not, with any changes to POC or other signifi-cant findings. Ob-tain report from CARE MANAGE-MENT nurse if CM patient.7

-If any assessments are out of parame-ters, contact MD for verbal orders and/or instructions. -Make appointment for next visit. Be sure to ask pt/cg about other appts. Remind pt/cg about visit frequency.

Complete Skilled Visit Note. Docu-ment specifically all assessDocu-ments & teaching in Cardiovascular section of Note. All other areas of note to be completed as appropriate, based on other deficits and/or comorbidities. Skilled Care - P. 4 of Note is complet-ed regarding all teaching & assess-ment not in Cardiovascular area. Document all collaboration with CM, MD and/or other services.

Refer to CFYH in “Written Instr Re”,” and “Outcome to Care”. Include pa-tient/ caregiver’s understanding and ability to learn and manage as well as any barriers to learning.

Examples of specific documentation:

• Pt/cg able to provide return

demo on daily weights. Need further instruction on complet-ing weight log

• Patient able to identify HCTZ

and state when to take and side effects, but did not re-member teaching from prior

visit on side effects of Vasotec.

• Began teaching food labels to

identify sodium content.

“Progress summary” includes areas still to be assessed and taught specifically those noted in examples above. “Plan next visit” should identify areas to be assessed and taught at next visit.

THIRD HOME VISIT

Clinical Assessment

Self Management Teaching with Patient/

Caregiver

Communication

/Collaboration

Documentation

Perform comprehensive assessment includ-ing:

Vital signs: Complete baseline vitals. BP: Take in arm identified at first visit. Us-ing that arm, take BP in the sit/stand mode or supine/ sit mode.

Pulses: both apical and radial with deficits noted.

Respiratory Assessment:

• Lung auscultation: Assess all lung fields for crackles, wheezes, rhonchi.

• Dyspnea: Assess level of dyspnea at rest and with activity.

• Cough and Orthopnea: Assess

• Chest pain: Assess any episodes of chest pain and actions taken.

Edema: Assess/document bilateral ankle/ calf (consistent 20 cms. above ankle bone mark) measurements in cms.

Weights:

• Review Weight Log on last page of CFYH. Observe patient weighing self.

• All weights are rounded down, i.e., 150.3 = 150. 180.8 = 180.

• Refer to Page 29. If patient’s weight is up 4 pounds or more from Target Weight, Medical Clinic is called. 212 423 7000. Identify self as HF patient and request immediate appt.

Medications: Assess med. compliance, any evidence of medication side effects and/or electrolyte imbalance. Assess patient ad-herence to ordered meds, identify barriers to compliance.

Ask patient/caregiver how they are doing and if they have any questions.

“How have you been feeling since our last visit? What would you like to discuss to-day?8”

Ask if Cardiology appt has occurred yet. Ask pa-tient/caregiver to report what occurred at appoint-ment. If there were any new medications pre-scribed, call MD to collaborate and obtain verbal order and write I.O. Begin teaching those changes. Daily Check up CFYH:

• Reassess patient/cg use pp 22-30 CFYH.

• Identify and address any barriers. Medications:

• Ask to see all medication bottles and ask patient for teach back regarding meds taught at prior visit. Reinstruct as needed. Teach any medica-tions not taught at prior visits.

• Review pp 3-8 including patient/cg’s documenta-tion on p. 8 CFYH.

• Identify barriers to learning and address. Nutrition:

• Assess pt/cg’s understanding of pps. 9-16 CFYH.

• Ask for teach back, if possible using foods in home as teaching tools with CFYH, especially pages 14 and 15, which have Food Labels.

• Assess any barriers to change and address. Exercise:

• Introduce pp. 17-21 in CFYH.

• Use p. 21 to develop goals.

•

Collaboration CARE MANAGE-MENT (CM)9_: Contact CM nurse at least weekly (Mon. preferred) whether CM pa-tient or not, with any changes to POC or other significant find-ings. If CM pa-tient, obtain re-port from CM nurse on their findings.10 If any assess-ments are out of parameters, con-tact MD for ver-bal orders and/or instruc-tions. Make appoint-ment for next visit and remind patient that you will be visiting 4 more times

Complete Skilled Visit Note.

• Document specifically all assessments and teaching in Cardiovascular section of Note. All other areas of note to be com-pleted as appropriate, based on other deficits and/or comorbidities.

• Skilled Care on P. 4 of Note is completed regarding all teaching and assessment not in Cardiovascular section.

• Document all collaboration with CM, MD and/or other services.

Refer to CFYH in “Written Instr Re,” and “Outcome to Care.” Include patient/ care-giver’s understanding and ability to learn and manage as well as any barriers to learning.

Examples of specific documentation:

• Pt/cg demonstrated ability to

achieve daily weights and now can document weights accurately

• Patient now able to teach back on

Vasotec and is compliant with meds as ordered.

• Pt/cg demonstrated use of food

labels to identify sodium. Pt begin-ning to slowly give up added salt.

• Pt/cg using Daily Check Up daily.

Pt stated “this helps me to remember to pay attention.” “Progress summary” includes areas still to be assessed and taught specifically those noted in examples above. “Plan next visit” should identify areas to be assessed and taught at next visit.

8_{Questions in this fontare ideas on how to begin visit. Use as appropriate} 9

FOURTH HOME VISIT

Clinical Assessment

Self Management Teaching with

Patient/Caregiver

Communication/

Collaboration

Documentation

Perform comprehensive assessment includ-ing:

Vital signs: Complete baseline vitals. BP: Take in arm identified at first visit. Us-ing that arm, take BP in the sit/stand mode or supine/ sit mode.

Pulses: both apical and radial with deficits noted.

Respiratory Assessment:

• Lung auscultation: Assess all lung fields for crackles, wheezes, rhonchi.

• Dyspnea: Assess level of dyspnea at rest and with activity.

• Cough and Orthopnea: Assess

• Chest pain: Assess any episodes of chest pain and actions taken.

Edema: Assess/document bilateral an-kle/calf (consistent 20 cms. above ankle bone mark) measurements in cms. Weights:

• Review Weight Log on last page of CFYH . Observe patient weighing self.

• All weights are rounded down, i.e., 150.3 = 150. 180.8 = 180.

• Refer to Page 29. If patient’s weight is up 4 pounds or more from Target Weight, Medical Clinic is called. 212 423 7000. Identify self as HF patient and request immediate appt.

Medications: Assess medication compliance and any evidence of medication side effects and/or electrolyte imbalance. Assess pa-tient adherence to ordered medications and identify barriers to compliance.

Ask patient/caregiver how they are doing and if they have any questions.

•“How have you been feeling since our last visit?

•What would you like to discuss today?

•What changes occurred since our last visit?11

Provide positive feedback for any chang-es patient/caregiver has begun including:

• Reading and documenting in CFYH • Adherence to medication regimen

• Adherence to any diet changes

• Assessing and recording weights

• Reviewing CFYH regularly

• Any other changes

Any changes are a big success. If pa-tient/caregiver has been able to make changes in some areas & not in others after giving positive feedback about changes, discuss barriers that impact ability to make other changes. Explain that change takes time and help pa-tient/caregiver to develop short and long term goals for change.

In CFYH, review as needed: Daily Check Up pp. 22-30 Medications pp 3-8 Nutrition pp. 9-16

Exercise pp 17-21 – As exercise was just taught at last visit, this may be the focus of your teaching.

Assess barriers to change in all above areas and address.

If CARE MANAGEMENT (CM)12

patient, equipment should be in home, fully operational. If not done at prior visit, ask patient to demonstrate use of House Calls equipment. Collaboration CARE MAN-AGEMENT: Report assess-ment to CM nurse at least weekly (preferably Mon.), whether CM patient or not. Collaborate regarding pa-tient/caregiver’s progress including: learning, compli-ance w/meds, weights, diet. Ensure CM nurse aware of all barriers identified. If CM pa-tient, obtain report from CM nurse re findings. 13

If any assessments are out of parameters, contact MD for verbal orders and/or instruc-tions.

Make appointment for next visit. Be sure to ask pt/cg about other appts. Remind pt/cg of visit frequency. If Care Management patient, you can assure them that the CM nurse will continue to work with them.

Complete Skilled Visit Note.

• Document specifically all assessments and teaching in Cardiovascular section of Note. All other areas of note to be completed as appropriate, based on other deficits and/or comorbidities.

• Skilled Care on P. 4 of Note is completed regarding all teaching, assessment not in Cardiovascular section.

• Document all collaboration with CM, MD and/or other services.

Refer to CFYH in “Written Instr Re,” & “Out-come to Care” should include

pa-tient/caregiver’s understanding, ability to learn & manage as well as any barriers to learning. “Progress summary” includes areas still to be assessed, taught.

Examples of specific documentation:

• Pt/cg demonstrated is now

famil-iar with CFYH. Needs further

in-struction/coaching on integrating exercise into daily life

• Pt has stopped adding salt at

most meals. Understands im-portance.

• Pt forgot to weigh and record

twice this week. Reinstructed on importance and verbalized under-standing and compliance.

• Pt/cg have begun walking daily for

10 mins.

“Plan next visit” should identify areas to be assessed and taught at next visit.

FIFTH HOME VISIT

Clinical Assessment

Self Management Teaching with

Patient/Caregiver

Communication/

Collaboration

Documentation

Vital signs: Complete baseline vitals.

BP: Take in arm identified at first visit. Using that arm, take BP in the sit/stand mode or supine/ sit mode.

Pulses: both apical and radial with deficits noted. Respiratory Assessment:

• Lung auscultation: Assess all lung fields for crack-les, wheezes, rhonchi.

• Dyspnea: Assess level of dyspnea at rest and with activity.

• Cough and Orthopnea: Assess

• Chest pain: Assess any episodes of chest pain and actions taken.

Edema: Assess/document bilateral ankle and calf (consistent 20 cms. above ankle bone mark) meas-urements in cms.

Weights:

• Review Weight Log on last page of CFYH. Observe patient weighing self.

• All weights are rounded down, i.e., 150.3 = 150. 180.8 = 180.

• Refer to Page 29. If patient’s weight is up 4 pounds or more from Target Weight, Medical Clinic is called. 212 423 7000. Identify self as HF patient and request immediate appt.

Medications: Assess medication compliance and any evidence of medication side effects and/or electro-lyte imbalance. Assess patient adherence to ordered medications and identify barriers to compliance.

Ask patient/caregiver how they are doing and if they have any questions.

• “How have you been feeling

since our last visit?

• What would you like to discuss

today?

• What changes occurred since our

last visit?14

Continue to provide positive feedback for any changes patient/caregiver has begun including:

• Reading and documenting in CFYH • Adherence to medication regimen

• Adherence to any diet changes

• Assessing and recording weights

• Reviewing CFYH regularly

• Any other changes

Discuss barriers that impact ability to make changes. Remind that change takes time and help patient/caregiver to devel-op short and long term goals for change. In CFYH, identify areas which need rein-forcement, reinstruction and provide same. Do pt/cg understand these are changes for life? How will they maintain change? Daily Check Up pp. 22-30 Medications pp 3-8 Nutrition pp. 9-16 Exercise pp 17-21 Weight log

Collaboration CARE MANAGE-MENT (CM):15 _{Whether CM} pa-tient or not, report assessment to CM nurse at least weekly (preferably Mon.) and collabo-rate regarding patient/ caregiv-er’s progress including: learning, compliance with medications, weights and diet. Ensure CM nurse is aware of any barriers you have identified for further education and coaching. If CM patient, obtain report from CM nurse on their findings.16 If any assessments are out of parameters, contact MD for ver-bal orders and/or instructions. Ensure Medical Clinic appoint-ment is set up and pt/caregiver knows when appointment is. Make appointment for next visit. Be sure to ask pt/cg about other appts. Remind pt/cg about visit frequency. Ask pt/cg to think about any areas in which they need more teaching or infor-mation. If they have CM, you can assure them that the CM nurse will continue to work with them.

Complete Skilled Visit Note as specified at prior visits (See visits 1-4)

Examples of specific

documention:

weigh daily and document same.

• Pt/cg sustaining

dai-ly walks and have increased time from 10 mins to 15 mins.

“Plan next visit” should identify areas to be as-sessed and taught at next visit.

14_{Questions in this fontare ideas on how to begin visit. Use as appropriate} 15

SIXTH HOME VISIT

Clinical Assessment

Self Management Teaching with

Patient/ Caregiver

Communication/

Collaboration

Documentation

Perform comprehensive assessment including: Vital signs: Complete baseline vitals.

BP: Take in arm identified at first visit. Using that arm, take BP in the sit/stand mode or supine/ sit mode. Pulses: both apical and radial with deficits noted. Respiratory Assessment:

• Lung auscultation: Assess all lung fields for crackles, wheezes, rhonchi.

• Dyspnea: Assess level of dyspnea at rest and with activity.

• Cough and Orthopnea: Assess

• Chest pain: Assess any episodes of chest pain and actions taken.

Edema: Assess/document bilateral ankle and calf (con-sistent 20 cms. above ankle bone mark) measurements in cms.

Weights:

• Review Weight Log on last page of CFYH. Observe patient weighing self.

• All weights are rounded down, i.e., 150.3 = 150. 180.8 = 180.

• Refer to Page 29. If patient’s weight is up 4 pounds or more from Target Weight, Medical Clinic is called. 212 423 7000. Identify self as HF patient and request immediate appt.

Medications: Assess medication compliance and any evidence of medication side effects and/or electrolyte imbalance. Assess patient adherence to ordered medi-cations and identify barriers to compliance.

Ask patient/caregiver how they are doing and if they have any questions. Remind them that your next visit will be your last visit.

• "What would you like to discuss

today?

• What changes have occurred

since our last visit?17

Provide positive feedback for any changes pt/cg have begun, no matter how small, including:

• Reading and documenting in CFYH • Adherence to medication regimen

• Adherence to any diet changes

• Assessing and recording weights

• Reviewing CFYH regularly

• Any other changes

Discuss barriers that impact ability to make changes. Remind that change takes time and help pt/cg develop short and long term goals for change. Ask pt/cg to continue to think about what they need from you prior to your next and last visit. In CFYH, identify areas which need rein-forcement, reinstruction and provide same. Does pt/cg understand these are changes for life? How will they maintain change? Daily Check Up pp. 22-30 Medications pp 3-8 Nutrition pp. 9-16 Exercise pp 17-21 Weight log

Collaboration CARE MAN-AGEMENT (CM):18 _Whether

House Calls patient or not, collaborate with CM nurse at least weekly (preferably Mon.) and communicate/ collaborate re any changes to POC . If CM patient, obtain report from CM nurse on their findings.19

If any assessments are out of parameters, contact MD for verbal orders and/or instruc-tions. If there is medical ne-cessity to continue visits, collaborate with MD, obtain verbal order, speak with your A.D.N., write I.O. and Managed Care Report to obtain auths if patient has managed care and submit documentation immediately.

Ensure Medical Clinic ap-pointment is set up and pt/caregiver knows when appointment is.

Complete Skilled Visit Note as specified at prior visits (See visits 1-4)

Specific documentation is re-quired. Examples follow:

• Pt/cg demonstrated full

familiarity with CFYH and

pt stated today “The Daily Check Up is my bible.”

• Pt has stopped adding

salt at all meals. Under-stands importance.

• Pt taking meds as

or-dered. Pt/cg has full un-derstanding of purpose, dose, route, frequency and side effects to report for all meds.

• Pt weighed and recorded

every day in last week. Verbalized understanding of importance of this.

• Pt/cg have begun walking

daily for 10 mins. Will dis-cuss other exercise ideas at next visit.

“Plan next visit” should identify areas to be assessed and taught at next visit.

23_{Questions in this fontare ideas on how to begin visit. Use as appropriate} 24

SEVENTH HOME VISIT

Clinical Assessment

Self Management Teaching with Patient/

Caregiver

Communication/

Collaboration

Documentation

Perform comprehensive assessment including: Vital signs: Complete baseline vitals.

BP: Take in arm identified at first visit. Using that arm, take BP in the sit/stand mode or supine/ sit mode.

Pulses: both apical and radial with deficits noted.

Respiratory Assessment:

• Lung auscultation: Assess all lung fields for crackles, wheezes, rhonchi.

• Dyspnea: Assess level of dyspnea at rest and with activity.

• Cough and Orthopnea: Assess

• Chest pain: Assess any episodes of chest pain and actions taken.

Edema: Assess/document bilateral ankle and calf (consistent 20 cms. above ankle bone mark)

measurements in cms.

Weights:

• Review Weight Log on last page of CFYH. Ob-serve patient weighing self.

• All weights are rounded down, i.e., 150.3 = 150. 180.8 = 180.

• Refer to Page 29. If patient’s weight is up 4 pounds or more from Target Weight, Medical Clinic is called. 212 423 7000. Identify self as HF patient and request immediate appt. Medications: Assess medication compliance and any evidence of medication side effects and/or electrolyte imbalance. Assess patient adherence to ordered medications and identify barriers to compliance.

Ask patient/caregiver how they are doing and if they have any questions. Remind them that this will be your last home visit.

• "This is my last visit. What would you like to discuss today?

• Let’s talk about your successes. How do you think you’ve changed and what do you think you’ve learned since we began work-ing together?

• What about areas you still need to grow regarding taking care of your heart. Would it be OK if we talked about some of

them?23

Summarize the month you’ve spent working with them. Provide positive feedback for any changes pt.cg have begun, no matter how small, including:

• Reading and documenting in CFYH • Adherence to medication regimen

• Adherence to any diet changes

• Assessing and recording weights

• Reviewing CFYH regularly

• Any other changes

Discuss barriers that impact ability to make changes. Remind that change takes time and help

pa-tient/caregiver to develop short and long term goals for change.

In CFYH, identify areas which need reinforcement, reinstruction and provide same. Does pt/cg under-stand these are changes for life? How will they main-tain change? Daily Check Up pp. 22-30 Medications pp 3-8 Nutrition pp. 9-16 Exercise pp 17-21 Weight log

Collaboration CARE MAN-AGEMENT (CM):24 Whether CM patient or not, collaborate w/CM nurse. Ensure CM nurse is fully aware of patient/ caregiver’s progress including: learning, compliance with medications, weights and diet. Ensure CM nurse is aware of any barriers you have identi-fied for further education and coaching. If CM patient, ob-tain report from CM nurse on their findings.25

If any assessments are out of parameters, contact MD for verbal orders and/or instruc-tions. If there is medical ne-cessity to continue visits, col-laborate w/MD, obtain verbal order, speak w/your A.D.N., write I.O. & Managed Care Report to obtain auths if pa-tient has mgd. care & submit documentation immediately.

If CM patient, assure pt/cg that the CM nurse will contin-ue to work with them. Ensure Medical Clinic appointment is set up and pt/caregiver knows date/time of appt.

Complete Discharge OASIS and Discharge Summary.

Specifics on your clinical note may includes some of the fol-lowing examples:

• Pt/cg will continue

with CM services.

• Pt’s BPs and weights

have ranged from ___ to __ during care episode. There was one episode of weight gain outside of parameters and pt’s diuretic was adjusted at Medical Clinic.

• Pt/cg has learned many

new skills to manage pt’s disease. Pt. now

uses CFYH as a daily

tool.

• Pt/cg use “The Daily

Check Up” in CFYH

dai-ly.

• Pt has stopped adding

salt at all meals. Un-derstands importance.

• Pt taking meds as

or-dered. Pt/cg has full understanding of pur-pose, dose, route, fre-quency, side effects to report for all meds.

•

walking daily for 10-15 mins. Plan to begin stretching and dancing