Premier Home Health Care
Transitional Care
Visits List
NP COPD 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, consider repeat lab testing including repeat CXR if appropriate)
Has patient seen PCP or specialist
Yes
No
Notes:
Meds reviewed and reconciled
All inhalers and nebulized meds
Yes
No
Notes:
BBlocker (if not, why not)
Yes
No
Why:
Can BBlocker be tapered or replaced?
Yes
No
Is patient on antibiotics?
Yes
No
When is End Date:
Tolerating increased activity
Yes
No
Respiratory status improving
Yes
No
Others (Specify)
Yes
No
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
Lab Tests (order additional as needed)
BNP
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, Inhaler review, 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
Nebulizer in home
Yes
No
Educated on
Proper use, and purpose, of each inhaler
Yes
No
Proper and safe use of oxygen
Yes
No
Warning signs of exacerbation
Yes
No
When and Whome to call if feeling worse
Yes
No
Activity and Dietary restrictions
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
Order lab tests , xrays, etc needed since last visit
Yes
No
Give immunizations decided on at Visit 1 (specify)
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
Specialist
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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