Premier Home Health Care
Transitional Care
Visits List
NP CARDIAC (CHF) CLINICAL PATHWAY - Visit 4
Validation
1
Assessment
2
Nutrition
3
Physical Exam
4
Lab Data
5
Education & Equipment
6
Plan
7
Signature
Interim History (Including adverse effects of medications)
Has patient seen PCP or Speciatlist
Yes
No
Notes:
Meds reviewed and reconciled
BBlocker (if not, why not)
Yes
No
Why:
ACE/ARB (if not, why not)
Yes
No
Why:
ASA (if not, why not)
Yes
No
Why:
SATIN (if not, why not)
Yes
No
Why:
Anticoagulant (which one)
Diuretics
Others (Specify)
Logs:
Daily Weight log reviewed
Yes
No
Notes:
Tolerating increased activity
Yes
No
Notes:
Respiratory status problem
Yes
No
Notes:
Chest pain or palpitations
Yes
No
Notes:
NA + Diet
Fluid Restriction
Yes
No
Current Weight
General Appearance
O2 Saturation
Blood Pressure
Respiratory Rate
Temprature
Pulse
Select:
Regular
Irregular
Afih
Neck Exam
Distended Neck Veins
Bruits
Lung Exam
Select:
Rales
Rhonchi
Breath Sounds
Cardiac Exam
Select:
Murmers
Rubs
Gallops
Abdominal Exam
Select:
Ascites
Hepatomegaly
Extermities
Edema (how much)?
Integument
Review all lab data from prior visit (Order additional as needed)
INR (If on Warfarin)
CBC
Dig level (If on Dig)
HgA1C (If Diabetes)
Lipid Profile
TSH
CXR
EKG
ECHO
EF
Date:
Reinforce education on all issues covered in Visit 1 (Especially Medication review including anticoagulation if appropriate. Daily Weights, Smoking cessation, Oxygen use and safety, Diet and activity
Scale in home
Yes
No
Educated on daily weight recording
Yes
No
Oxygen in home
Yes
No
CPAP
Yes
No
Educated on
Post-procedure sxs (If applicable)
Yes
No
Antocoagulation instruction (If applicable)
Yes
No
"Red Flag" Symptoms
Yes
No
When and Whome to call if feeling worse
Yes
No
Activity and Dietary restrictions
Yes
No
Use and Safety of Oxygen (If present)
Yes
No
Smoking cessation (If needed)
Yes
No
Final Medication Reconciliation
Yes
No
"Teach back" method used
Yes
No
At the last visit, be sure patient has a follow up appointment with PCP, and that patient and Care Team are fully aware of it
Follow up on appointments planned and/or needed
Yes
No
Follow up with anticoagulation instructions
Yes
No
Give immunizations decided on at Visit 1 (Specify)
Yes
No
Notes:
Order Labs tests including xrays etc needed since last visit
Yes
No
Instructions Report
Report with instructions left with patient
Yes
No
Final Report Sent To
Care Team
Yes
No
PCP
Yes
No
Specialist
Yes
No
CHHA (If appropriate)
Yes
No
Finished
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