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. SN removed dressing from left ankle. No s/s of secondary infection, surrounding skin intact. SN performed wound care to left ankle as follows: clean site with NS solution, pat dry, apply Medihoney sheet, cover with 4×4 gauze, wrap with kerlix and secure with tape, every other day. Procedures were done following aseptic techniques and universal precautions were used. Patient tolerated procedure well without complaint or complications. Patient is incapable of perform wound care due: complexity of procedure. There is no caregiver willing and able to perform this skilled care. SN educated Pt/ CG how prevent pressure ulcers: Provide appropriate support surface, reposition every two hours in bed, off-load heels (use pillows or positioning boot), reposition every hour when in chair, use pillow between legs for side lying, do not position directly on trochanter, do not use doughnut-type devices. Caregiver verbalized understanding teaching.