VIEW COMPLETED NOTE

Patient identified with Name, DOB, ID and Address prior to perform all procedures. SN performed skilled observation and assessment, monitored vital signs, assessed mental, physical and behavioral status. Instructed, evaluated and assessed pt compliance, effectiveness and side effects to medications. Instructed on diet plan. Assessed patient understanding of disease process. Patient education provided. Assessed & educated patient knowledge of signs and symptoms re: complications necessitating medical attention. Instructed patient in any knowledge deficit. Assessed home for safety & Risks for Falls. Safety & preventative education provided. Implemented safety measures as needed. SN prepared and administered 5000 units of Heparin to left upper quadrant (LUQ) of abdomen, every twelve hours. Patient tolerated injection well without bleeding at site, complaint or complication. Standard and universal precautions were used. Patient is unable to perform injection due complexity of procedure. Patient is unable to learn the technique to safely inject this medication due complexity of procedure. There is no caregiver willing and available to perform this skilled care. SN instructed patient / caregiver that any injection procedure, infection at the site of injection is a possibility. Signs of infection at the injection site include: severe pain, redness, swelling, warmth or drainage. These symptoms should be reported to your physician immediately. Patient/caregiver verbalized understanding teaching.