Other Services Involved (By Current Agency)

Other Agencies Involved

Medical Diagnosis (Diagnosis lookup)

Inpatient Facilities ICD10 Codes

Use Coding Expert? top

Yes

Karnofsky Performance Status Scale

checked /> 100 - Normal, no complaints, no evidence of disease checked /> 90 - Able to carry on normal activity, minor signs or symptoms of disease checked /> 80 - Normal activity with effort; some S/S of disease checked /> 70 - Cares for self; unable to carry on normal activity or to do active work checked /> 60 - Requires considerable assistance, but is able to care for most personal needs checked /> 50 - Requires considerable assistance and frequent medical care checked /> 40 - Disabled; requires special care and assistance checked /> 30 - Severely disabled; hospital admission necessary, active supportive tx nec. checked /> 20 - Very sick - hospital admission necessary; active supportive treatment nec. checked /> 10 - Moribund, fatal processes progressing rapidly checked /> 0 - Dead

Skin

checked /> Bruise(s) checked /> Color Cyanotic checked /> Color Jaundice checked /> Color Pale checked /> Dry Skin checked /> Poor Skin Turgor checked /> Rash(es) checked /> Sweaty Skin checked /> Asymptomatic checked /> Other

Nutrition

checked /> Overweight checked /> Underweight checked /> Recent Significant weight loss checked /> Recent Significant weight gain checked /> Problems with chewing, swallowing checked /> Problems with teeth/dentures checked /> Asymptomatic checked /> Other

Endocrine

checked /> Hyperglycemia: Thirst, Tiredness, Apathy, increased Sleeping checked /> Hypoglycemia: Hunger, Dizziness, Shaking, Nervousness between 65 - 99 mg/dL'>checked /> Serum <> between 65 - 99 mg/dL checked /> Sugar in urine checked /> Asymptomatic checked /> Other

Nutritional Therapies

checked /> 1 - Intravenous or Infusion Therapy (excludes TPN) checked /> 2 - Parenteral Nutrition (TPN or liquids) checked /> 3 - Enteral Nutrition (Nasogastric, Gastrostomy, Jejunostomy, etc) checked /> 4 - None of the above

Pain assessment complete Pain assessment incomplete

Update Pain Level

Pain Assessment

Pain Level

checked/> pain level 0 (low) checked/> pain level 1 (low) checked/> pain level 2 (low) checked/> pain level 3 (med) checked/> pain level 4 (med) checked/> pain level 5 (med)

checked/> pain level 6 (med) checked/> pain level 7 (high) checked/> pain level 8 (high) checked/> pain level 9 (high) checked/> pain level 10 (high)

Pain Assessment Complete

Pain assessment incomplete


0	1	2	3	4	5

Pain Characteristics

checked/> Throbbing checked/> Stabbing checked/> Sharp checked /> Aching checked/> Burning

checked /> Numb checked/> Asymptomatic checked/> Shooting checked/> Not Applicable checked/> Other

Pain Threshold

checked/> At rest checked /> With minimal activity checked/> With moderate activity checked/> With strenuous activity checked/> Asymptomatic checked/> Other checked/> Not Applicable

Rate current pain

checked/> pain level 0 (low) checked/> pain level 1 (low) checked/> pain level 2 (low) checked/> pain level 3 (med) checked/> pain level 4 (med) checked/> pain level 5 (med)

checked/> pain level 6 (med) checked/> pain level 7 (high) checked/> pain level 8 (high) checked/> pain level 9 (high) checked/> pain level 10 (high)


0	1	2	3	4	5

How long does each

checked/> 30 minutes checked/> 1 hour checked/> 2 hours checked/> 3 hours checked/> 4 hours checked/> 6 hours

checked/> 12 hours checked/> 24 hours checked/> More than 24 hours checked/> Not Applicable checked/> Other

What Is Patient'S Opinion?

checked/> Physical Activity
checked/> Disease Process
checked/> Not Applicable
checked/> Other

Cardio-Respiratory-Hematology

checked /> Abnormal lab results checked /> Breath Sounds not clear checked /> Dependent Edema checked /> Dizziness, Headaches checked /> Dyspnea, Shortness of breath checked /> High Blood Pressure checked /> Nosebleeds checked /> Palpitations, Diaphoresis checked /> Sputum not Clear, Scant, Watery checked /> Weakness/Fatigue checked /> Asymptomatic checked /> Other

Genitourinary/Catheter

checked /> Abnormal Lab results checked /> Abnormal Urine frequency checked /> Excoriation of surrounding skin checked /> Genital Discharge checked /> Genital Inflamm checked /> Genital Lesions checked /> Urine color not Pale Yellow checked /> Urine Odor not Faint checked /> Asymptomatic checked /> Other

Gastrointestinal

checked /> Abnormal Stool Lab checked /> Bowel Sounds not Soft Gurgling 5-35/min checked /> Constipation checked /> Diarrhea checked /> Excoriation of Surrounding Skin checked /> Asymptomatic checked /> Other

Musculo-Skeletel

checked /> Abnormal Gait and Station checked /> Limited Range of Motion checked /> Limited Muscle Strength checked /> Impaired Coordination checked /> Multiple Falls in the last 6 months checked /> Weakness checked /> Asymptomatic checked /> Other

Ostomy

checked /> Constipation checked /> Diarrhea checked /> Excoriation of Surrounding Skin checked /> Flatulence checked /> Asymptomatic checked /> Other

Neurological

checked /> Aphasia checked /> Breath Sounds not Clear checked /> Hallucinations checked /> Headaches checked /> Long Term Memory Limits 10 - 14 seconds'>checked /> PT <> 10 - 14 seconds 22 - 45 seconds'>checked /> PTT <> 22 - 45 seconds checked /> Pupils fixed checked /> Short Term Memory Limits checked /> Sputum not Clear, Scant, Watery checked /> Stupor checked /> Tremors, Handgrip Weakness checked /> Asymptomatic checked /> Other

Home Safety

checked /> Unsafe Stairs and/or Doorways checked /> Rugs, Cords and/or Furniture causing Safety Risk checked /> Inadequate Heating and/or Cooling checked /> Unsafe Appliances checked /> Inadequate Sanitation and/or Plumbing checked /> Inadequate Refrigeration checked /> Presence of Insects and/or Rodents checked /> Inadequate Smoke Detectors checked /> O2 in use without precautions checked /> Home has no hazards checked /> Other

Home Health Aide Indicators

checked /> Light Housekeeping Needed checked /> Light Meal Prep Needed checked /> Shopping Needed checked /> Errands Needed checked /> Companionship Needed checked /> Caregiver Respite Needed checked /> Emotional Support Needed checked /> Other

Comments