Premier Home Health Care
Transitional Care
Visits List
NP JOINT REPLACEMENT (CJR) CLINICAL PATHWAY - Visit 4
Validation
1
Assessment
2
Nutrition
3
Physical Exam
4
Lab Data
5
Education & Equipment
6
Plan
7
Signature
Interim history (iincluding adverse effects of medications)
Has patient seen PCP or Surgeon
Yes
No
Comorbidities:
Peri Op Complications:
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:
Any significant dietary or weight changes?
Yes
No
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
Determine if staples are ready to come out
Yes
No
Lab Tests (Order additional labs as needed)
INR (If on Warfarin)
CBC
Dig level (If on Dig)
HgA1C (If Diabetes)
Lipid Profile
TSH
CXR
Urinalysis
Reinforce education on all issues review topics covered in Visit 1. Especially: Medication review including anticoagulation regimen,Pain medication,Lab review. Reinforce rehab exercise protocol to improve mobility, transfers, walking with gait aid, strength, flexibility (ROM), independence in ADLs. With attention to anticoagulation and possible tapering of pain regimen when possible
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
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 on INR and warfarin dosing if appropriate
Yes
No
Remove staples if indicated and approved by surgeon
Yes
No
Give immunizations decided on at Visit 1 (specify)
Yes
No
Order lab tests , xrays, etc as needed since last visit
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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1
Validation states
2
Alerts
3
Payment Info
4
Other Info
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