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. PICC Line dressing changed following aseptic technique standard precautions and proper container for disposed. Old dressing removed and discarded from right arm. Site without redness, swelling or exudate, or any other s/s complications. Patient denies discomfort at site, or along vein track. Catheter has 10 cm external, which corresponds to previous external measurements. Per sterile technique, area cleansed with antiseptic from kit and allowed to air dry. Secured with statlock, followed by transparent sterile membrane (tegaderm). Needleless cap also changed and line flushed with 10 cc NSS 0.9% after obtaining brisk blood return. Labeled site with date and initials. Patient is incapable of perform IV dressing change due: complexity of procedure. There is no caregiver willing and able to perform this skilled care.