Client's General Appearance: Good Fair Poor Level of Care: Last Follow Up PSS Schedule: PSS Saturdays:

Nurse

Vital Signs BP HR RR BG PsOx Weight Last Visit:

OBSERVATION / ASSESSMENT: (*) New problem (+) Continuous problem (±) Periodic problem

Allergies

10. DIET Diabetic Low Sodium Low Fat / Low Cholesterol Renal Regular Other

11. HYGIENE Toileting Bathing Oral Hygiene Dressing Eating

12. ACTIVITY LEVEL Independent Assistance needed: Total Moderate Minimum

13. MENTAL STATUS Alert Oriented Disoriented Forgetful Depressed Anxious Agitated Other

14. HEALTH MONITORING (check if any changes from previous SV): -mental status? Yes No - functional status? Yes No - medical condition? Yes No - treatment regimen? Yes No - medication regimen? Yes No - skin integrity? Yes No - level of mobility? Yes No

15. Any recent falls? Yes No

16. Any recent hospitalizations or ER visits? Yes No

17. Any teachings / instructions provided? Yes No

18. Last Doctor's appointment? Date Reason:

19. Is client satisfied with provided services? Yes No

Comments: