Premier Home Health Care
Transitional Care
Visits List
NP JOINT REPLACEMENT (CJR) CLINICAL PATHWAY - Visit 1
Validation
1
Assessment
2
Nutrition
3
Physical Exam
4
Lab Data
5
Education & Equipment
6
Plan
7
Signature
History of Present Illiness
Hip or Knee Replacement
Yes
No
Date of Surgery:
Comorbidities:
Peri Op Complications:
Allergies reviewed
Yes
No
Allergies:
Meds reviewed and reconciled
Pain Meds
Yes
No
Specify:
Anticoagulation:
Warfarin
Yes
No
Why:
LMW heparin
Yes
No
Why:
ASA
Yes
No
Why:
Other Meds (which one)
Bowel Regimen
Others (Specify)
Assess:
Assess Pain Mobility
Yes
No
Notes:
Assess mobility, activity level, ability to transfer, awareness of precautions, walking with gait aid
Yes
No
Notes:
Ability to do ADLs
Yes
No
Notes:
Current Diet
Current Weight
General Appearance
O2 Saturation
Blood Pressure
Respiratory Rate
Temprature
Pulse
Regular/Irregular:
Regular
Irregular
Neck Exam
Distended Neck Veins
Bruits
Lung Exam
Rales
Rhonchi
Breath Sounds
Cardiac Exam
Murmers
Rubs
Gallops
Abdominal Exam
Ascites
Hepatomegaly
Extermities
Edema
Yes
No
Calf tederness
Yes
No
Wound Clean
Yes
No
Healing
Yes
No
Lab Tests
INR (If on Warfarin)
CBC
Dig level (If on Dig)
HgA1C (If Diabetes)
Lipid Profile
TSH
CXR
Urinalysis
Gait aid in home
Yes
No
Raised toilet seat
Yes
No
Other equipment needed
Educated on
Hospital discharge instructions
Yes
No
Anticoagulation regimen (including self-injection if needed)
Yes
No
Pain regimen and med safety
Yes
No
Bowel regimen
Yes
No
Final med reconciliation
Yes
No
"Teach back" method used
Yes
No
Joint precautions (especially after Hip surgery)
Yes
No
Wound care
Yes
No
Signs of infection, DVT, or pulmonary emboli to watch for
Yes
No
When and whom to call with questions
Yes
No
Order Labs including daily INR (If needed), x-rays as needed
Yes
No
CHHA needed
Yes
No
Post op surgery appointment needed?
Yes
No
PCP appointment needed?
Yes
No
Confirm rehab schedule (OT and PT)
Yes
No
Immunizations needed for next visits
Flu
Yes
No
Pneumonia
Yes
No
Shingles
Yes
No
Instructions Report
Report with instructions left with patient
Yes
No
Report Sent To
Care Team
Yes
No
PCP
Yes
No
Surgeon
Yes
No
CHHA (If appropriate)
Yes
No
Finished
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