Nurse Practitioner-Vorlage
NP hospice face to face note
Eine professionelle Nurse Practitioner-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
Need a clear and concise way to document hospice patient visits? This **hospice face-to-face note template** is designed for Nurse Practitioners and other hospice care providers. It helps you efficiently record essential information like patient symptoms, family input, and treatment plans. This template ensures you capture all necessary details for recertification and ongoing care. With Heidi, this template can be quickly populated from your patient encounter, saving you time and ensuring accurate medical documentation.
Vorlagenvorschau
Hospice Nurse Practitioner Face-to-Face Visit Template
Patient Name: Mrs. Evelyn Carter
Age/Gender: 82, Female
Code Status: DNR
Allergies: NKDA
Admission Date: 20 October 2024
Date of Visit: 1 November 2024
Recertification Period: 60 days
Benefit Period: 3
Primary Admitting Diagnosis: Metastatic Breast Cancer
Other Pertinent Diagnosis: COPD, Hypertension
Medications: Morphine Sulfate 10mg PO q4h PRN for pain, Lorazepam 0.5mg PO q6h PRN for anxiety, Oxygen 2L via nasal cannula
Subjective:
- Primary Concerns: Patient reports increased shortness of breath and worsening pain despite current medication regimen.
- Family/Caregiver Input: Daughter reports increased confusion and decreased oral intake over the past week.
- Patient’s Expressed Wishes (if applicable): Patient wishes to remain at home and is adamant about comfort care.
Objective:
- General Appearance: Frail, cachectic, appears uncomfortable.
- Neurological: Confused, oriented to person only.
- Respiratory: Labored breathing, scattered wheezes.
- Cardiac: Regular rate and rhythm, no edema.
- Gastrointestinal: Poor oral intake, bowel sounds present.
- Skin: Skin is dry, with stage 1 pressure ulcer on sacrum.
Assessment:
- Clinical Findings: Worsening dyspnea, increased pain, decline in functional status consistent with advanced metastatic breast cancer.
- Functional Status/Evidence of Decline: PPS score of 30%.
Plan:
- Medication Adjustments: Increase Morphine Sulfate to 15mg PO q4h PRN for pain. Add Dexamethasone 4mg PO daily for dyspnea.
- Symptom Management: Continue oxygen therapy. Educate family on signs of respiratory distress and provide comfort measures.
- Coordination with Hospice Team: Schedule follow-up visit in 2 days. Discuss with social worker for family support and education.
Attestation:
I attest that I have completed a face-to-face encounter with this patient and that the clinical findings documented above support a terminal prognosis. This documentation will be provided to the certifying physician for use in determining continued eligibility for hospice care. Upon submission of my visit note, my electronic signature will be placed on the face-to-face attestation as part of the certification of terminal illness.
Signed:
Dr. Jane Smith, CNP
1 November 2024
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