VIEW COMPLETED NOTE

Patient identified by name, ID with picture and facial recognition. SN performed skilled observation and assessment of all body systems from head to toe. No signs or symptoms of acute distress noted. SN assessed home for safety & Risks for fall. Safety & preventative education. SN performed skilled observation and assessment, monitored vital sign and blood pressure and found them within normal limits. SN assessed mental and physical status, evaluated compliance, effectiveness and side effects of medication, diet and nutritional status, and patient’s and/or caregiver’s knowledge of signs and symptoms of complication. Once infection control measures are applied, the procedure is explained and the patient was positioning for comfort; volume of balloon was aspirated with syringe; catheter was withdrawal gently and discard equipment appropriately. Patient tolerated procedure well without bleeding at site, complaint or complication. Patient is unable to perform self-care due: functional, physical, and mental limitations. There is no caregiver willing and able to perform this skilled care. SN instructed Pt/CG regarding the complications after remove Foley catheter (urinary retention, dysuria, frequency, hematuria, incontinence) and Call MD/SN if: do not urinate at all within 8 hours of your catheter removal, have a fever, leaking urine, have urinary urgency, frequency, or trouble urinating for more than 48 hours after catheter removal. Have pain while you urinate, or you feel like your bladder is not emptying completely for more than 48 hours after catheter removal. See blood in your urine and the abdomen is bloated. Patient/caregiver verbalized understanding teaching.