Shortcut Examples (Insert Text)

Fall Prevention

Educated on slow positional changes and slow directional changes. Educated on proper and consistent use of ambulatory assist device. Educated on durable medical equipment needed in the home to maintain safety and highest level of functional mobility independence. Educated on medication side effects which may increase risk of falls.

Standard Walker Education

Patient/caregiver was instructed on safety precautions to be observed while using standard walker as follows:

1. Clear all the cables and cords that can be on the way for the walker. They can entangle to the walker legs and lead to impaired balance and fall.

2. Maintain the floor dry. Wipe any spillage immediately. Any wetness of the floor can contribute to slipping, loss of balance, and fall injury.

3. Wear comfortable clothes when using walker. Loose and frizzy clothing on the lower body can get entangled with the walker legs, compromise balance, and lead to fall.

4. Always wear appropriate non-skid footwear while using walker. Walker users stand the risk of hurting their feet with the walker legs sometimes, while maneuvering with the walker around. Having shoes on can offer protection against any injuries to the feet.

5. Make sure the carpet in the house is evenly spread and secured. Uneven carpet with bumpy contour can obstruct the walker legs, impair balance, and contribute to increased fall risk.

6. Make sure you perform timely inspections on the walker or have it inspected, as recommended, to ensure the device is in proper functional state. Also, make sure the walker seat is stable and supporting your weight enough while sitting on it. If the walker is wobbly or if the walker seat is unstable or you notice the structure broken, have the walker repaired or replaced. Using a broken walker or one with unstable legs and seat can result in serious falls and accidents.

Lungs Normal

Lungs clear to percussion and auscultation. Normal sinus rhythm. No premature beat, murmur, S3 or S4. Heart sounds are of good quality and intensity. The carotids, femorals, dorsalis pedis, and posterior tibial pulsations are brisk, equal, and active bilaterally.

IV Infusion

Initiated IV infusion of (MEDICATION/SOLUTION) at (AMOUNT)mL/hr using (GUAGE) IV catheter located in the (BODY-LOCATION). The IV site is free from pain, coolness, redness, or swelling.

Hospice Admit

Patient was admitted on ADMIT_DATE with hospice dx of PRIMARY_DIAGNOSIS.

Comorbid conditions include: DICTATE_ADDITONAL_CONDITIONS

Consent for care signed by NAME_AND_RELATIONSIP_TO_PATIENT

Primary contact for this patient is NAME_AND_PHONE_NUMBER

Unsafe Gait

Patient is unable to safely use their (WALKER,WHEELCHAIR,CANE) due to (WEAKNESS,DIZZINESS,COGNITIVE-IMPAIRMENTS) and must have the assistance of another person to safely leave the house.

Behavioral Pain Assessment

FACIAL EXPRESSION = [Relaxed(1)/Partially-tightened-e.g.brow-lowering(2)/Fully-tightened-e.g.eyelid-closing(3)/Grimacing(4)]

UPPER LIMB MOVEMENTS = [No-movement(1)/Partially-bent(2)/Fully-bent-with-finger-flexion(3)/Permanently-retracted(4)]

COMPLIANCE WITH MECHANICAL VENTILATION = [Tolerating-movement(1)/Coughing-but-tolerating-ventilation-most-of-the-time(2)/Fighting-ventilator(3)/Unable-to-control-ventilation(4)]

CAM-S Confusion Assessment

- Acute onset of symptom fluctuation: ABSENT(0)/PRESENT(1)

- Inattention: ABSENT(0)/MILD(1)/MARKED(2)

- Disorganized thinking: ABSENT(0)/MILD(1)/MARKED(2)

- Altered level of consciousness: ABSENT(0)/MILD(1)/MARKED(2)

SCORE = ___ / 7

Sign Documentation

Dictated on ${simpleDateFormat:EEE MMM dd KK:mm:ss a zzz yyyy} by ${NVOQ _FIRST_NAME_INITIAL }.${NVOQ _LAST_NAME }

Dictated on Thu Dec 07 01:30:53 PM 2023 by G.Glass

Reviewed Sign and Date

Reviewed by ${ NVOQ _FIRST_NAME}  ${NVOQ _LAST_NAME },  ${DATE:us}

Reviewed by George Glass, 12/08/23