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. Blood-sugar was checked via by finger-stick, blood sugar level 120 mmol/l. SN prepared and administered 15 Units of Lantus Sub-Q to right upper thigh plus sliding scale coverage of 5 Units of Novolog Sub-Q to right lower quadrant (RLQ) of abdomen. Procedures were done following standard and universal precautions. Patient tolerated injection well without bleeding at site, complaint or complication. Patient is incapable of BS testing and or administer own insulin due complexity of procedure. Patient is unable to learn the technique to safely inject insulin due functional, physical, and mental limitations. There is no caregiver willing and able to perform this skilled care. Instructed patient/caregiver on food and diabetes, tips to manage Blood sugar following a proper diet. Instructed to use sugar substitutes instead or regular sugar. To watch for added sugar in juice and powdered drinks. Patient/caregiver verbalized understanding teaching.