Premier Home Health Care
Transitional Care
Visits List
NP DIABETES 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
Allergies reviewed
Yes
No
Allergies:
Meds reviewed and reconciled
Oral hypoglycemics
Yes
No
Why:
Insulin
Yes
No
Long-Acting
Short-Acting
ACEI/ARB (if not, why not)
Yes
No
Why:
ASA (if not, why not)
Yes
No
Why:
Statin (if not, why not)
Yes
No
Why:
Antihypertensives (if needed)
Yes
No
Others (Specify)
NA + Diet
Well balanced diet
Yes
No
No concentrated sweets
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 (Ulceration?)
Neurologic (loss of sensation, or ankle reflexes, in feet)?
Lab Tests
CBC
HgA1C (If Diabetes)
Lipid Profile
Urinalysis
Urine microalbumin
Glucose monitor in home
Yes
No
Educated on
Use of insulin (if needed)
Yes
No
Home glucose monitoring
Yes
No
HghAiC target
Yes
No
Complications of DM
Yes
No
Foot Safety
Yes
No
Need for ophthal, podiatry checks
Yes
No
Nephrology consult if needed
Yes
No
Smoking cessation (If needed)
Yes
No
Final Medication Reconciliation
Yes
No
"Teach back" method used
Yes
No
Order Labs, x-rays as needed
Yes
No
Review/arrange appointments with PCP and/or Specialist
Yes
No
Podiatry, Ophth, Nephrol appontments needed
Yes
No
CHHA needed
Yes
No
Rehab needed
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
Specialist
Yes
No
CHHA (If appropriate)
Yes
No
Finished
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Alerts
3
Payment Info
4
Other Info
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