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<div style="text-align: center;"><strong style="font-size: 18pt;">SKILLED NURSING PROGRESS NOTE</strong></div> <hr /> <div></div> </div> <div><fieldset><legend title="VITAL SIGNS"><span style="color: #ff0000; font-size: 14pt;">VITAL SIGNS</span></legend> <table style="width: 902px; height: 48px;" align="center" border="1" bordercolor="" cellpadding="2" cellspacing="2" width="902"> <tbody> <tr> <td>Temp:<input runat="server" id="TempTEXT" value="" value="" value="" name="TempTEXT" type="text" /></td> <td>BP:<input runat="server" id="BPTEXT" value="" value="" value="" name="BPTEXT" type="text" /></td> </tr> </tbody> <tbody> <tr> <td>PR:<input runat="server" id="PRTEXT" value="" value="" value="" name="PRTEXT" type="text" /></td> <td>RR:<input runat="server" id="RRTEXT" value="" value="" value="" name="RRTEXT" type="text" /></td> </tr> </tbody> <tbody> <tr> <t
d>WT:<input runat="server" id="WTTEXT" value="" value="" value="" name="WTTEXT" type="text" /></td> <td>Pulse OX:<input runat="server" id="PulseOXTEXT" value="" value="" value="" name="PulseOXTEXT" type="text" /></td> </tr> </tbody> <tbody> <tr> <td>RBS:<input runat="server" id="RBSTEXT" value="" value="" value="" name="RBSTEXT" type="text" /></td> <td>Time:<input runat="server" id="RBSTimeTEXT" value="" value="" value="" name="RBSTimeTEXT" type="text" /></td> </tr> </tbody> <tbody> <tr> <td>FBS:<input runat="server" id="FBSTEXT" value="" value="" value="" name="FBSTEXT" type="text" /></td> <td>Time:<input runat="server" id="FBSTimeTEXT" value="" value="" value="" name="FBSTimeTEXT" type="text" /></td> </tr> </tbody> <tbody> <tr> <td> <span><input runat="server" id="GlucometerteCHECKBOXst" name="GlucometertestCHECKBOX" value="ch
eckBox5" type="checkbox" />Glucometer Test Completed Today</span></td> <td> <span><input runat="server" id="patAlertOrientedCHECKBOX" name="patAlertOrientedCHECKBOX" value="checkBox5" type="checkbox" />Patient Alert and Oriented</span></td> </tr> </tbody> </table> </fieldset> </div> <div><fieldset><legend title=""><span style="color: #ff0000; font-size: 14pt;"></span></legend> <table style="width: 902px; height: 48px;" align="center" border="1" bordercolor="" cellpadding="2" cellspacing="2" width="902"> <tbody> <tr> <td> Pain:<select name="PainDROPDOWN" size="0" runat="server" id="PainDROPDOWN"> <option selected=""></option> <option value="0">0</option> <option value="1">1</option> <option value="2">2</option> <option value="3">3</option> <option value="4">4</option> <option value="5">5</option> <option value="6">6</o
ption> <option value="7">7</option> <option value="8">8</option> <option value="9">9</option> <option value="10">10</option> </select>(0-No Pain, 10 Severe pain) </td> <td> Location:<textarea cols="60" rows="4" name="LocationTEXT" runat="server" id="LocationTEXT" value="Location of pain revised" value="Location of pain">Location of pain</textarea> </td> </tr> </tbody> </table> </fieldset> <div><fieldset><legend title="NURSING ASSESSMENT OF SIGNS AND SYMPTOMS"><span style="color: #ff0000; font-size: 14pt;">NURSING ASSESSMENT OF SIGNS AND SYMPTOMS</span></legend> <table style="width: 902px; height: 48px;" align="center" border="1" bordercolor="" cellpadding="2" cellspacing="2" width="902"> <tbody> <tr> <td><span><input runat="server" id="problemnotedCHECKBOX" name="problemnotedCHECKBOX" value="checkBox1" type="checkbox" />Problems Noted<label for="checkBox1"></label></span></td>
<td><span><input runat="server" id="noproblemnotedCHECKBOX" name="noproblemnotedCHECKBOX" value="checkBox1" type="checkbox" />No Problems Noted<label for="checkBox1"></label></span></td> </tr> </tbody> </table> </fieldset> </div> <div><fieldset><legend title="Nervous System"><span style="color: #ff0000; font-size: 14pt;">NERVOUS SYSTEM</span></legend> <table style="width: 902px; height: 48px;" align="center" border="1" bordercolor="" cellpadding="2" cellspacing="2" width="902"> <tbody> <tr> <td> <span><input runat="server" id="HeadacheCHECKBOX" name="HeadacheCHECKBOX" value="checkBox9" type="checkbox" />Headache<br /> </span></td> <td> <span><input runat="server" id="SyncopeCHECKBOX" name="SyncopeCHECKBOX" value="checkBox10" type="checkbox" />Syncope</span> </td> </tr> </tbody> <tbody> </tbody> <tbody> <tr> <td> Grasp:</td> <td> <span><input ru
nat="server" id="RtCHECKBOX" name="RtCHECKBOX" value="checkBox10" type="checkbox" />Rt</span> </td> <td> <span><input runat="server" id="LtCHECKBOX" name="LtCHECKBOX" value="checkBox10" type="checkbox" />Lt</span> </td> </tr> </tbody> <tbody> <tr> <td> Movement:</td> <td> <span><input runat="server" id="RUECHECKBOX" name="RUECHECKBOX" value="checkBox10" type="checkbox" />RUE</span> </td> <td> <span><input runat="server" id="LUECHECKBOX" name="LUECHECKBOX" value="checkBox10" type="checkbox" />LUE</span> </td> <td> <span><input runat="server" id="RLECHECKBOX" name="RLECHECKBOX" value="checkBox10" type="checkbox" />RLE</span> </td> <td> <span><input runat="server" id="LLECHECKBOX" name="LLECHECKBOX" value="checkBox10" type="checkbox" />LLE</span> </td> </tr> </tbody> <tbody> <tr> <td> Pupillary Reaction:</td> <
td> <span><input runat="server" id="PPRCHECKBOXt" name="PPRtCHECKBOX" value="checkBox10" type="checkbox" />Rt</span> </td> <td> <span><input runat="server" id="PPLtCHECKBOX" name="PPLtCHECKBOX" value="checkBox10" type="checkbox" />Lt</span> </td> <td> <span><input runat="server" id="TremorCHECKBOX" name="TremorCHECKBOX" value="checkBox10" type="checkbox" />Tremor</span> </td> <td> <span><input runat="server" id="VertigoCHECKBOX" name="VertigoCHECKBOX" value="checkBox10" type="checkbox" />Vertigo</span> </td> </tr> </tbody> <tbody> <tr> <td>Sensory </td> <td> <span><input runat="server" id="SpeechImpairmentCHECKBOX" name="SpeechImpairmentCHECKBOX" value="checkBox10" type="checkbox" />Speech Impairment</span> </td> <td> <span><input runat="server" id="VisualImpairmentCHECKBOX" name="VisualImpairmentCHECKBOX" value="checkBox10" type="checkbox" />Visual Impairment</
span> </td> <td> <span><input runat="server" id="HearingImpairmentCHECKBOX" name="HearingImpairmenCHECKBOXt" value="checkBox10" type="checkbox" />Hearing Impairment</span> </td> <td> <span><input runat="server" id="TactileSenseCHECKBOX" name="TactileSenseCHECKBOX" value="checkBox10" type="checkbox" />Tactile Sense</span> </td> </tr> </tbody> </table> </fieldset></div> <div><fieldset><legend title="Nervous System"><span style="color: #ff0000; font-size: 14pt;">GENITO URINARY</span></legend> <table style="width: 902px; height: 48px;" align="center" border="1" bordercolor="" cellpadding="2" cellspacing="2" width="902"> <tbody> <tr> <td> <span><input runat="server" id="BurningCHECKBOX" name="BurningCHECKBOX" value="checkBox10" type="checkbox" />Burning</span> </td> <td> <span><input runat="server" id="DistentionCHECKBOX" name="DistentionCHECKBOX" value="checkBox10" type="checkbox" />Distention/Retent
ion</span> </td> <td> <span><input runat="server" id="FrequencyCHECKBOX" name="FrequencyCHECKBOX" value="checkBox10" type="checkbox" />Frequency/Urgency</span> </td> <td> <span><input runat="server" id="BladderCHECKBOX" name="BladderCHECKBOX" value="checkBox10" type="checkbox" />Bladder Incontinence</span> </td> </tr> </tbody> <tbody> <tr> <td> <span><input runat="server" id="CatheterCHECKBOX" name="CatheterCHECKBOX" value="checkBox10" type="checkbox" />Catheter</span> <select name="catheterDROPDOWN" size="0" runat="server" id="catheterDROPDOWN"> <option selected=""></option> <option value="Foley">Foley</option> <option value="Suprapubic">Suprapubic</option> <option value="Condom">Condom</option> </select> </td> <td> <span><input runat="server" id="PainCHECKBOX" name="PainCHECKBOX" value="checkBox10" type="checkbox" /
>Pain</span> </td> <td> <span><input runat="server" id="HesitancyCHECKBOX" name="HesitancyCHECKBOX" value="checkBox10" type="checkbox" />Hesitancy</span> </td> <td> <span><input runat="server" id="HematuriaCHECKBOX" name="HematuriaCHECKBOX" value="checkBox10" type="checkbox" />Hematuria</span> </td> </tr> </tbody> <tbody> <tr> <td> <span><input runat="server" id="UrineColorCHECKBOX" name="UrineColorCHECKBOX" value="checkBox10" type="checkbox" />Urine Color</span> </td> <td> <span><input runat="server" id="UrineSedimentCHECKBOX" name="UrineSedimentCHECKBOX" value="checkBox10" type="checkbox" />Urine Sediment</span> </td> <td> <span><input runat="server" id="UrineOdorCHECKBOX" name="UrineOdorCHECKBOX" value="checkBox10" type="checkbox" />Urine Odor</span> </td> </tr> </tbody> <tbody> <tr> <td>Mus
culo/Skeletal</td> <td> <span><input runat="server" id="BalUnsteadygaitCHECKBOX" name="BalUnsteadygaitCHECKBOX" value="checkBox10" type="checkbox" />Bal/Unsteady gait</span> </td> </tr> </tbody> <tbody> <tr> <td>Weakness</td> <td> <span><input runat="server" id="WeaknessRtCHECKBOX" name="WeaknessRtCHECKBOX" value="checkBox10" type="checkbox" />Rt</span> </td> <td> <span><input runat="server" id="WeaknessLtCHECKBOX" name="WeaknessLtCHECKBOX" value="checkBox10" type="checkbox" />Lt</span> </td> <td> <span><input runat="server" id="WeaknessMobilityCHECKBOX" name="WeaknessMobilityCHECKBOX" value="checkBox10" type="checkbox" />Mobility</span> </td> </tr> </tbody> </table> </fieldset></div> <div><fieldset><legend title="CARDIOPULMONARY"><span style="color: #ff0000; font-size: 14pt;">CARDIOPULMONARY</span></legend> <table style="width: 902px; height: 48px;" align="center" b
order="1" bordercolor="" cellpadding="2" cellspacing="2" width="902"> <tbody> <tr> <td> <span><input runat="server" id="ChestPainCHECKBOX" name="ChestPainCHECKBOX" value="checkBox10" type="checkbox" />Chest Pain</span> </td> </tr> </tbody> <tbody> <tr> <td>Edema</td> <td> <select name="edemaRUEDROPDOWN" size="0" runat="server" id="edemaRUEDROPDOWN"> <option selected=""></option> <option value="T">T</option> <option value="1">1+</option> <option value="2">2+</option> <option value="3">3+</option> <option value="4">4+</option> </select>RUE </td> <td> <select name="edemaLUEDROPDOWN" size="0" runat="server" id="edemaLUEDROPDOWN"> <option selected=""></option> <option value="T">T</option> <option value="1">1+</option> <option val
ue="2">2+</option> <option value="3">3+</option> <option value="4">4+</option> </select>LUE </td> </tr> </tbody> <tbody> <tr> <td><br /> </td> <td><select name="edemaRLEDROPDOWN" size="0" runat="server" id="edemaRLEDROPDOWN"> <option selected=""></option> <option value="T">T</option> <option value="1">1+</option> <option value="2">2+</option> <option value="3">3+</option> <option value="4">4+</option> </select>RLE </td> <td> <select name="edemaLLEDROPDOWN" size="0" runat="server" id="edemaLLEDROPDOWN"> <option selected=""></option> <option value="T">T</option> <option value="1">1+</option> <option value="2">2+</option> <option value="3">3+</option> <option value="4">4+</option> </select>LLE
</td> </tr> </tbody> <tbody> <tr> <td> <span><input runat="server" id="DizzinessCHECKBOX" name="DizzinessCHECKBOX" value="checkBox10" type="checkbox" />Dizziness</span> </td> <td> <span><input runat="server" id="ArrythmiaCHECKBOX" name="ArrythmiaCHECKBOX" value="checkBox10" type="checkbox" />Arrythmia</span> </td> <td> <span><input runat="server" id="NeckVeinDistentionCHECKBOX" name="NeckVeinDistentionCHECKBOX" value="checkBox10" type="checkbox" />Neck Vein Distention</span> </td> </tr> </tbody> <tbody> <tr> <td>Peripheral Pulses</td> <td> <span><input runat="server" id="PeripheralPulsesRtCHECKBOX" name="PeripheralPulsesRtCHECKBOX" value="checkBox10" type="checkbox" />Rt</span> </td> <td> <span><input runat="server" id="PeripheralPulsesLtCHECKBOX" name="PeripheralPulsesLtCHECKBOX" value="checkBox10" type="checkbox" />Lt</span>
<select name="edemaLLEDROPDOWN" size="0" runat="server" id="edemaLLEDROPDOWN"> <option selected=""></option> <option value="Pedal">Pedal</option> <option value="Poplateal">Poplateal</option> </select></td> </tr> </tbody> <tbody> <tr> <td>Respiratory:</td> </tr> </tbody> <tbody> <tr> <td> <span><input runat="server" id="RalesRhonchiWheezesCHECKBOX" name="RalesRhonchiWheezesCHECKBOX" value="checkBox10" type="checkbox" />Rales/Rhonchi/Wheezes</span> </td> <td> <span><input runat="server" id="CoughCHECKBOX" name="CougCHECKBOXh" value="checkBox10" type="checkbox" />Cough</span> </td> <td> <span><input runat="server" id="DyspneaSOBCHECKBOX" name="DyspneaSOBCHECKBOX" value="checkBox10" type="checkbox" />Dyspnea/SOB</span> </td> </tr> </tbody> <tbody> <tr> <td> <span><i
nput runat="server" id="OrthopneaCHECKBOX" name="OrthopneaCHECKBOX" value="checkBox10" type="checkbox" />Orthopnea</span> </td> <td> <span><input runat="server" id="DiminishedBSCHECKBOX" name="DiminishedBSCHECKBOX" value="checkBox10" type="checkbox" />Diminished BS</span> </td> </tr> </tbody> </table> </fieldset></div> <div><fieldset><legend title="SKIN/INTEGUMENTARY"><span style="color: #ff0000; font-size: 14pt;">SKIN/INTEGUMENTARY</span></legend> <table style="width: 902px; height: 48px;" align="center" border="1" bordercolor="" cellpadding="2" cellspacing="2" width="902"> <tbody> <tr> <td> <span><input runat="server" id="ClammyCHECKBOX" name="ClammyCHECKBOX" value="checkBox10" type="checkbox" />Clammy</span> </td> <td> <span><input runat="server" id="JaundiceCHECKBOX" name="JaundiceCHECKBOX" value="checkBox10" type="checkbox" />Jaundice</span> </td> <td> <span><input runat="server" id="PallorC
HECKBOX" name="PallorCHECKBOX" value="checkBox10" type="checkbox" />Pallor</span> </td> <td> <span><input runat="server" id="TurgorCHECKBOX" name="TurgorCHECKBOX" value="checkBox10" type="checkbox" />Turgor</span> </td> <td> <span><input runat="server" id="RashCHECKBOX" name="RashCHECKBOX" value="checkBox10" type="checkbox" />Rash</span> </td> </tr> </tbody> <tbody> <tr> <td> <span><input runat="server" id="DrynessCHECKBOX" name="DrynessCHECKBOX" value="checkBox10" type="checkbox" />Dryness</span> </td> <td> <span><input runat="server" id="ShinglesLesionsCHECKBOX" name="ShinglesLesionsCHECKBOX" value="checkBox10" type="checkbox" />Shingles Lesions</span> </td> <td> <span><input runat="server" id="SurgicalWoundCHECKBOX" name="SurgicalWoundCHECKBOX" value="checkBox10" type="checkbox" />Surgical Wound</span> </td> <td> <span><input runat="server" id="PressureSores
CHECKBOX" name="PressureSoresCHECKBOX" value="checkBox10" type="checkbox" />Pressure Sores</span> </td> <td> <span><input runat="server" id="DiabeticUlcerCHECKBOX" name="DiabeticUlcerCHECKBOX" value="checkBox10" type="checkbox" />Diabetic Ulcer</span> </td> </tr> </tbody> <tbody> <tr> <td> <span><input runat="server" id="RecentSkinGraftCHECKBOX" name="RecentSkinGraftCHECKBOX" value="checkBox10" type="checkbox" />Recent Skin Graft</span> </td> <td> <span><input runat="server" id="FungalInfectionCHECKBOX" name="FungalInfectionCHECKBOX" value="checkBox10" type="checkbox" />Fungal Infection</span> </td> <td> <span><input runat="server" id="OtherWoundCHECKBOX" name="OtherWoundCHECKBOX" value="checkBox10" type="checkbox" />Other Wound</span> </td> </tr> </tbody> </table> </fieldset></div> <div><fieldset><legend title="DIGESTIVE"><span style="color: #ff0000; font-size: 14pt;">DIGESTIVE</s
pan></legend> <table style="width: 902px; height: 48px;" align="center" border="1" bordercolor="" cellpadding="2" cellspacing="2" width="902"> <tbody> <tr> <td> <span><input runat="server" id="NauseaVomitingCHECKBOX" name="NauseaVomitingCHECKBOX" value="checkBox10" type="checkbox" />Nausea/Vomiting</span> </td> <td> <span><input runat="server" id="AnorexiaCHECKBOX" name="AnorexiaCHECKBOX" value="checkBox10" type="checkbox" />Anorexia</span> </td> <td> <span><input runat="server" id="EpigastricDistressCHECKBOX" name="EpigastricDistressCHECKBOX" value="checkBox10" type="checkbox" />Epigastric Distress</span> </td> <td> <span><input runat="server" id="DiffSwallowingCHECKBOX" name="DiffSwallowingCHECKBOX" value="checkBox10" type="checkbox" />Diff. Swallowing</span> </td> <td> <span><input runat="server" id="DiarrheaCHECKBOX" name="DiarrheaCHECKBOX" value="checkBox10" type="checkbox" />Diarrhea</span
> </td> </tr> </tbody> <tbody> <tr> <td> <span><input runat="server" id="ConstipImpactionCHECKBOX" name="ConstipImpactionCHECKBOX" value="checkBox10" type="checkbox" />Constip/Impaction</span> </td> <td> <span><input runat="server" id="BowelIncontinenceCHECKBOX" name="BowelIncontinenceCHECKBOX" value="checkBox10" type="checkbox" />Bowel Incontinence</span> </td> <td> <span><input runat="server" id="ColostomyCHECKBOX" name="ColostomyCHECKBOX" value="checkBox10" type="checkbox" />Colostomy</span> </td> <td> <span><input runat="server" id="PegTubeCHECKBOX" name="PegTubeCHECKBOX" value="checkBox10" type="checkbox" />Peg Tube</span> </td> <td> <span><input runat="server" id="AbsentBowelSoundsCHECKBOX" name="AbsentBowelSoundsCHECKBOX" value="checkBox10" type="checkbox" />Absent Bowel Sounds</span> </td> </tr> </tbody> <tbody> <tr> <td>Emotio
nal/Mental:</td> </tr> </tbody> <tbody> <tr> <td> <span><input runat="server" id="AnxiousCHECKBOX" name="AnxiousCHECKBOX" value="checkBox10" type="checkbox" />Anxious</span> </td> <td> <span><input runat="server" id="DisorientedCHECKBOX" name="DisorientedCHECKBOX" value="checkBox10" type="checkbox" />Disoriented</span> </td> <td> <span><input runat="server" id="ForgetfulCHECKBOX" name="ForgetfulCHECKBOX" value="checkBox10" type="checkbox" />Forgetful</span> </td> <td> <span><input runat="server" id="DepressedCHECKBOX" name="DepressedCHECKBOX" value="checkBox10" type="checkbox" />Depressed</span> </td> <td> <span><input runat="server" id="LethargicCHECKBOX" name="LethargicCHECKBOX" value="checkBox10" type="checkbox" />Lethargic</span> </td> </tr> </tbody> </table> </fieldset></div> <div><fieldset><legend title="INTERVENTIONS/INSTRUCTIONS (Skilled Services Rendere
d):"><span style="color: #ff0000; font-size: 14pt;">INTERVENTIONS/INSTRUCTIONS (Skilled Services Rendered):</span></legend> <table style="width: 902px; height: 48px;" align="center" border="1" bordercolor="" cellpadding="2" cellspacing="2" width="902"> <tbody> <tr> <td> <span><input runat="server" id="SkilledObservationCHECKBOX" name="SkilledObservationCHECKBOX" value="checkBox10" type="checkbox" />Skilled Observation</span> </td> <td> <span><input runat="server" id="O2SafetyCHECKBOX" name="O2SafetyCHECKBOX" value="checkBox10" type="checkbox" />O2 Safety</span> </td> <td> <span><input runat="server" id="FingerstickBloodSugarCHECKBOX" name="FingerstickBloodSugarCHECKBOX" value="checkBox10" type="checkbox" />Prep/Adm. Insulin</span> </td> <td> <span><input runat="server" id="DepressedCHECKBOX" name="DepressedCHECKBOX" value="checkBox10" type="checkbox" />Fingerstick Blood Sugar</span> </td> </tr> </tb
ody> <tbody> <tr> <td> <span><input runat="server" id="BowelBladderTrainingCHECKBOX" name="BowelBladderTrainingCHECKBOX" value="checkBox10" type="checkbox" />Bowel/Bladder Training</span> </td> <td> <span><input runat="server" id="FoleyCareInsertionCHECKBOX" name="FoleyCareInsertionCHECKBOX" value="checkBox10" type="checkbox" />Foley Care/Insertion</span> </td> <td> <span><input runat="server" id="EvalADLsCHECKBOX" name="EvalADLsCHECKBOX" value="checkBox10" type="checkbox" />Eval ADLs</span> </td> <td> <span><input runat="server" id="DisimpactionEnemaCHECKBOX" name="DisimpactionEnemaCHECKBOX" value="checkBox10" type="checkbox" />Disimpaction Enema</span> </td> </tr> </tbody> <tbody> <tr> <td> <span><input runat="server" id="TeachAdmTubeFeedCHECKBOX" name="TeachAdmTubeFeedCHECKBOX" value="checkBox10" type="checkbox" />Teach/Adm Tube Feed</span> </td> <
td> <span><input runat="server" id="WoundCareDressingCHECKBOX" name="WoundCareDressingCHECKBOX" value="checkBox10" type="checkbox" />Wound Care/Dressing</span> </td> <td> <span><input runat="server" id="TeachDisProcessCHECKBOX" name="TeachDisProcessCHECKBOX" value="checkBox10" type="checkbox" />Teach Dis. Process</span> </td> <td> <span><input runat="server" id="PostOPCareCHECKBOX" name="PostOPCareCHECKBOX" value="checkBox10" type="checkbox" />Post OP Care</span> </td> </tr> </tbody> <tbody> <tr> <td> <span><input runat="server" id="TeachERPlanCHECKBOX" name="TeachERPlanCHECKBOX" value="checkBox10" type="checkbox" />Teach ER Plan</span> </td> <td> <span><input runat="server" id="TrachCareObservationCHECKBOX" name="TrachCareObservationCHECKBOX" value="checkBox10" type="checkbox" />Trach Care/Observation</span> </td> <td> <span><input runat="server" id="TeachSafetyMeasuresCHEC
KBOX" name="TeachSafetyMeasuresCHECKBOX" value="checkBox10" type="checkbox" />Teach Safety Measures</span> </td> <td> <span><input runat="server" id="MedReconciliationCHECKBOX" name="MedReconciliationCHECKBOX" value="checkBox10" type="checkbox" />Med Reconciliation</span> </td> </tr> </tbody> <tbody> <tr> <td> <span><input runat="server" id="VenipunctureCHECKBOX" name="VenipunctureCHECKBOX" value="checkBox10" type="checkbox" />Venipuncture</span> </td> <td> <span><input runat="server" id="TeachAdmINHRxCHECKBOX" name="TeachAdmINHRxCHECKBOX" value="checkBox10" type="checkbox" />Teach/Adm INH Rx</span> </td> <td> <span><input runat="server" id="TeachAdmIVCHECKBOX" name="TeachAdmIVCHECKBOX" value="checkBox10" type="checkbox" />Teach/Adm IV</span> <select name="teachadminDROPDOWN" size="0" runat="server" id="teachadminDROPDOWN"> <option selected=""></option> <opti
on value="Lovenox">Lovenox</option> <option value="Procrit">Procrit</option> <option value="B12">B12</option> </select></td> <td> <span><input runat="server" id="TeachDietHydrationCHECKBOX" name="TeachDietHydrationCHECKBOX" value="checkBox10" type="checkbox" />Teach Diet/Hydration</span> </td> </tr> </tbody> <tbody> <tr> <td> <span><input runat="server" id="PainAssessMgmtCHECKBOX" name="PainAssessMgmtCHECKBOX" value="checkBox10" type="checkbox" />Pain Assess/Mgmt</span> </td> <td> <span><input runat="server" id="FallPrecautionsCHECKBOX" name="FallPrecautionsCHECKBOX" value="checkBox10" type="checkbox" />Fall Precautions</span> </td> <td> <span><input runat="server" id="TeachDiabCareObservationCHECKBOX" name="TeachDiabCareObservationCHECKBOX" value="checkBox10" type="checkbox" />Teach Diab Care/Observation</span> </td> <td> <span><input run
at="server" id="TeachProvideOstomyCareCHECKBOX" name="TeachProvideOstomyCareCHECKBOX" value="checkBox10" type="checkbox" />Teach/Provide Ostomy Care</span> </td> </tr> </tbody> <tbody> <tr> <td> <span><input runat="server" id="EvalTeachMedESECHECKBOX" name="EvalTeachMedESECHECKBOX" value="checkBox10" type="checkbox" />Eval/Teach Med E/SE</span> </td> <td> <span><input runat="server" id="ManagementEvalCHECKBOX" name="ManagementEvalCHECKBOX" value="checkBox10" type="checkbox" />Management Eval</span> </td> </tr> </tbody> </table> </fieldset></div> <div><fieldset><legend title=""><span style="color: #ff0000; font-size: 14pt;"></span></legend> <table style="width: 902px; height: 48px;" align="center" border="1" bordercolor="" cellpadding="2" cellspacing="2" width="902"> <tbody> <tr> <td> <span><input runat="server" id="OthersCHECKBOX" name="OthersCHECKBOX" value="checkBox10" type="checkbo
x" />Others</span> <textarea cols="48" rows="4" name="IntInsOtherTEXT" runat="server" id="IntInsOtherTEXT" value=",,," value=",,,">,</textarea></td> </tr> </tbody> </table> </fieldset></div> <div><fieldset><legend title=""><span style="color: #ff0000; font-size: 14pt;"></span></legend> <table style="width: 902px; height: 48px;" align="center" border="1" bordercolor="" cellpadding="2" cellspacing="2" width="902"> <tbody> <tr> <td> Subjective Data <textarea cols="48" rows="4" name="SubjectiveDataTEXT" runat="server" id="SubjectiveDataTEXT"></textarea> </td> </tr> </tbody> <tbody> <tr> <td>Objective Data <textarea cols="48" rows="4" name="ObjectiveDataTEXT" runat="server" id="ObjectiveDataTEXT"></textarea> </td> </tr> </tbody> <tbody> <tr> <td>Specific Clinical Problem <textarea cols="48" rows="4" name="SpecificClinicalProblemTEXT" runat="server" id="SpecificClinicalP
roblemTEXT"></textarea> </td> </tr> </tbody> <tbody> <tr> <td>Nursing Action Related to Services Provided <textarea cols="48" rows="4" name="NursingActionRelatedtoServicesProvidedTEXT" runat="server" id="NursingActionRelatedtoServicesProvidedTEXT"></textarea> </td> </tr> </tbody> </table> </fieldset></div> <div><fieldset><legend title="INTERVENTIONS/INSTRUCTIONS (Skilled Services Rendered):"><span style="color: #ff0000; font-size: 14pt;">INTERVENTIONS/INSTRUCTIONS (Skilled Services Rendered):</span></legend> <table style="width: 902px; height: 48px;" align="center" border="1" bordercolor="" cellpadding="2" cellspacing="2" width="902"> <tbody> <tr> <td> <span><input runat="server" id="RequiresassistancetoambulateCHECKBOX" name="RequiresassistancetoambulateCHECKBOX" value="checkBox10" type="checkbox" />Requires assistance to ambulate</span> </td> <td> <span><input runat="server" id="Unable
tosafelyleaveCHECKBOX" name="UnabletosafelyleaveCHECKBOX" value="checkBox10" type="checkbox" />Unable to safely leave the home unassisted</span> </td> <td> <span><input runat="server" id="SevereSOBDyspneaCHECKBOX" name="SevereSOBDyspneaCHECKBOX" value="checkBox10" type="checkbox" />Severe SOB/Dyspnea upon exertion</span> </td> </tr> </tbody> <tbody> <tr> <td> <span><input runat="server" id="DependentuponadaptiveCHECKBOX" name="DependentuponadaptiveCHECKBOX" value="checkBox10" type="checkbox" />Dependent upon adaptive device(s)</span> </td> <td> <span><input runat="server" id="O2DependentCHECKBOX" name="O2DependentCHECKBOX" value="checkBox10" type="checkbox" />O2 Dependent</span> </td> <td> <span><input runat="server" id="NeedsassistanceCHECKBOX" name="NeedsassistanceCHECKBOX" value="checkBox10" type="checkbox" />Needs assistance for all activities/ADL</span> </td> </tr> </tbody>
<tbody> <tr> <td> <span><input runat="server" id="MedicalrestrictionCHECKBOX" name="MedicalrestrictionCHECKBOX" value="checkBox10" type="checkbox" />Medical restriction</span> </td> <td> <span><input runat="server" id="ImpairedmobilityCHECKBOX" name="ImpairedmobilityCHECKBOX" value="checkBox10" type="checkbox" />Impaired mobility/Muscle weakness</span> </td> <td> <span><input runat="server" id="CVInstabilityCHECKBOX" name="CVInstabilityCHECKBOX" value="checkBox10" type="checkbox" />CV Instability</span> </td> </tr> </tbody> </table> </fieldset></div> <div><fieldset><legend title=""><span style="color: #ff0000; font-size: 14pt;"></span></legend> <table style="width: 902px; height: 48px;" align="center" border="1" bordercolor="" cellpadding="2" cellspacing="2" width="902"> <tbody> <tr> <td> <span><input runat="server" id="patreqothers" name="patreqothers" value="checkBox10" type="checkbo
x" />Others</span> <textarea cols="48" rows="4" name="IntInsOtherTEXT" runat="server" id="IntInsOtherTEXT" value=",,," value=",,,">,</textarea> </td> </tr> </tbody> </table> </fieldset></div> <div><fieldset><legend title="CLIENT / CAREGIVER RESPONSE OUTCOME:"><span style="color: #ff0000; font-size: 14pt;">CLIENT / CAREGIVER RESPONSE OUTCOME:</span></legend> <table style="width: 902px; height: 48px;" align="center" border="1" bordercolor="" cellpadding="2" cellspacing="2" width="902"> <tbody> <tr> <td> <span><input runat="server" id="FollowthroughConsistencyCHECKBOX" name="FollowthroughConsistencyCHECKBOX" value="checkBox10" type="checkbox" />Follow through Consistency</span> </td> <td> <span><input runat="server" id="DemonstrateReturnDemoCHECKBOX" name="DemonstrateReturnDemoCHECKBOX" value="checkBox10" type="checkbox" />Demonstrate/Return Demo</span> </td> <td> <span><input runat="server" id="FollowthroughInconsis
tencyCHECKBOX" name="FollowthroughInconsistencyCHECKBOX" value="checkBox10" type="checkbox" />Follow through Inconsistency</span> </td> </tr> </tbody> <tbody> <tr> <td> <span><input runat="server" id="InadequatecomprehensionCHECKBOX" name="InadequatecomprehensionCHECKBOX" value="checkBox10" type="checkbox" />Inadequate comprehension</span> </td> <td> <span><input runat="server" id="RequiresContinuesTeachingCHECKBOX" name="RequiresContinuesTeachingCHECKBOX" value="checkBox10" type="checkbox" />Requires Continues Teaching</span> </td> <td> <span><input runat="server" id="ImprovingCHECKBOX" name="ImprovingCHECKBOX" value="checkBox10" type="checkbox" />Improving</span> </td> </tr> </tbody> <tbody> <tr> <td> <span><input runat="server" id="AnxiousCHECKBOX" name="AnxiousCHECKBOX" value="checkBox10" type="checkbox" />Unstable</span> </td> <td> <span><input
runat="server" id="DisorientedCHECKBOX" name="DisorientedCHECKBOX" value="checkBox10" type="checkbox" />Deteriorating</span> </td> <td> <span><input runat="server" id="ForgetfulCHECKBOX" name="ForgetfulCHECKBOX" value="checkBox10" type="checkbox" />Verbal Undestanding</span> </td> </tr> </tbody> </table> </fieldset></div> <div><fieldset><legend title="AIDE SUPERVISORY VISIT:"><span style="color: #ff0000; font-size: 14pt;">AIDE SUPERVISORY VISIT:</span></legend> <table style="width: 902px; height: 48px;" align="center" border="1" bordercolor="" cellpadding="2" cellspacing="2" width="902"> <tbody> <tr> <td>Aide in the Case? <span><input runat="server" id="AideyesCHECKBOX" name="AideyesCHECKBOX" value="checkBox10" type="checkbox" />Yes</span> <span><input runat="server" id="AidnoCHECKBOX" name="AidnoCHECKBOX" value="checkBox10" type="checkbox" />No</span> </td> </tr> </tbody> </table> </fieldset></div> <d
iv><fieldset><legend title=""><span style="color: #ff0000; font-size: 14pt;"></span></legend> <table style="width: 902px; height: 48px;" align="center" border="1" bordercolor="" cellpadding="2" cellspacing="2" width="902"> <tbody> <tr> <td>Aide present on this visit? <input runat="server" id="presentyesCHECKBOX" name="presentyesCHECKBOX" value="checkBox10" type="checkbox" />Yes <span><input runat="server" id="presentnoCHECKBOX" name="presentnoCHECKBOX" value="checkBox10" type="checkbox" />No</span> </td> </tr> </tbody> </table> </fieldset></div> <div><fieldset><legend title=""><span style="color: #ff0000; font-size: 14pt;"></span></legend> <table style="width: 902px; height: 48px;" align="center" border="1" bordercolor="" cellpadding="2" cellspacing="2" width="902"> <tbody> <tr> <td>Aide following care plan? <input runat="server" id="followingyesCHECKBOX" name="followingyesCHECKBOX" value="chec
kBox10" type="checkbox" />Yes <span><input runat="server" id="followingnoCHECKBOX" name="followingnoCHECKBOX" value="checkBox10" type="checkbox" />No</span> </td> </tr> </tbody> </table> </fieldset></div> <div><fieldset><legend title=""><span style="color: #ff0000; font-size: 14pt;"></span></legend> <table style="width: 902px; height: 48px;" align="center" border="1" bordercolor="" cellpadding="2" cellspacing="2" width="902"> <tbody> <tr> <td>Courteous and Polite? <input runat="server" id="courteousyesCHECKBOX" name="courteousyesCHECKBOX" value="checkBox10" type="checkbox" />Yes <span><input runat="server" id="courteousnoCHECKBOX" name="courteousnoCHECKBOX" value="checkBox10" type="checkbox" />No</span> </td> </tr> </tbody> </table> </fieldset></div> <div><fieldset><legend title=""><span style="color: #ff0000; font-size: 14pt;"></span></legend> <table style="width: 902px; height: 48px;" align="center"
border="1" bordercolor="" cellpadding="2" cellspacing="2" width="902"> <tbody> <tr> <td>Patient Satisfied with care? <input runat="server" id="satisfiedyesCHECKBOX" name="satisfiedyesCHECKBOX" value="checkBox10" type="checkbox" />Yes <span><input runat="server" id="satisfiednoCHECKBOX" name="satisfiednoCHECKBOX" value="checkBox10" type="checkbox" />No</span> </td> </tr> </tbody> </table> </fieldset></div> <div><fieldset><legend title=""><span style="color: #ff0000; font-size: 14pt;"></span></legend> <table style="width: 902px; height: 48px;" align="center" border="1" bordercolor="" cellpadding="2" cellspacing="2" width="902"> <tbody> <tr> <td>Changes made to care plan? <input runat="server" id="changesyesCHECKBOX" checked checked name="changesyesCHECKBOX" value="checkBox10" type="checkbox" />Yes <span><input runat="server" id="changesnoCHECKBOX" name="changesnoCHECKBOX" value="check
Box10" type="checkbox" />No</span> </td> </tr> </tbody> </table> </fieldset></div> <div><fieldset><legend title=""><span style="color: #ff0000; font-size: 14pt;"></span></legend> <table style="width: 902px; height: 48px;" align="center" border="1" bordercolor="" cellpadding="2" cellspacing="2" width="902"> <tbody> <tr> <td>Comments <textarea cols="48" rows="4" name="aideCommentsTEXT" runat="server" id="aideCommentsTEXT"></textarea> </td> </tr> </tbody> </table> </fieldset></div> <div><fieldset><legend title="COMMUNICATION:"><span style="color: #ff0000; font-size: 14pt;">COMMUNICATION:</span></legend> <table style="width: 902px; height: 48px;" align="center" border="1" bordercolor="" cellpadding="2" cellspacing="2" width="902"> <tbody> <tr> <td>COORDINATION MADE WITH: </td> <td> <span><input runat="server" id="COORDINATIONPTCHECKBOX" name="COORDINATIONPTCHECKBOX" value=
"checkBox10" type="checkbox" />PT</span> </td> <td> <span><input runat="server" id="COORDINATIONOTCHECKBOX" name="COORDINATIONOTCHECKBOX" value="checkBox10" type="checkbox" />OT</span> </td> <td> <span><input runat="server" id="COORDINATIONCHHACHECKBOX" name="COORDINATIONCHHACHECKBOX" value="checkBox10" type="checkbox" />CHHA</span> </td> </tr> </tbody> <tbody> <tr> <td> </td> <td> <span><input runat="server" id="COORDINATIONMSWCHECKBOX" name="COORDINATIONMSWCHECKBOX" value="checkBox10" type="checkbox" />MSW</span> </td> <td> <span><input runat="server" id="COORDINATIONSTCHECKBOX" name="COORDINATIONSTCHECKBOX" value="checkBox10" type="checkbox" />ST</span> </td> <td> <span><input runat="server" id="COORDINATIONMDCHECKBOX" name="COORDINATIONMDCHECKBOX" value="checkBox10" type="checkbox" />MD</span> </td> </tr> </tbody> <tbody> <tr>
<td> </td> <td> <span><input runat="server" id="COORDINATIONRNCHECKBOX" name="COORDINATIONRNCHECKBOX" value="checkBox10" type="checkbox" />RN SUPERVISOR</span> </td> <td> <span><input runat="server" id="COORDINATIONDIETCHECKBOX" name="COORDINATIONDIETCHECKBOX" value="checkBox10" type="checkbox" />DIETICIAN</span> </td> <td> <span><input runat="server" id="COORDINATIONCLIENTCHECKBOX" name="COORDINATIONCLIENTCHECKBOX" value="checkBox10" type="checkbox" />CLIENT SERVICES</span> </td> </tr> </tbody> <tbody> <tr> <td>REGARDING PATIENTS: </td> <td> <span><input runat="server" id="REGARDINGTODAYCHECKBOX" name="REGARDINGTODAYCHECKBOX" value="checkBox10" type="checkbox" />Todays Visit/Assessment</span> </td> <td> <span><input runat="server" id="REGARDINGfunctionalCHECKBOX" name="REGARDINGfunctionalCHECKBOX" value="checkBox10" type="checkbox" />Functio
nal Status</span> </td> <td> <span><input runat="server" id="REGARDINGpocCHECKBOX" name="REGARDINGpocCHECKBOX" value="checkBox10" type="checkbox" />Plan of Care</span> </td> </tr> </tbody> </table> </fieldset></div> <div><fieldset><legend title=""><span style="color: #ff0000; font-size: 14pt;"></span></legend> <table style="width: 902px; height: 48px;" align="center" border="1" bordercolor="" cellpadding="2" cellspacing="2" width="902"> <tbody> <tr> <td>Others: <textarea cols="48" rows="4" name="REGARDINGotherTEXT" runat="server" id="REGARDINGotherTEXT"></textarea> </td> </tr> </tbody> </table> </fieldset></div> <div><fieldset><legend title="Pt/Family Informed of Changes and Participated in Plan of Care::"><span style="color: #ff0000; font-size: 14pt;">Pt/Family Informed of Changes and Participated in Plan of Care:</span></legend> <table style="width: 902px; height: 48px;" align="center" border="1" bor
dercolor="" cellpadding="2" cellspacing="2" width="902"> <tbody> <tr> <td>Changes made to care plan? <input runat="server" id="ChangespocyesCHECKBOX" name="ChangespocyesCHECKBOX" value="checkBox10" type="checkbox" />Yes <span><input runat="server" id="ChangespocnoCHECKBOX" name="ChangespocnoCHECKBOX" value="checkBox10" type="checkbox" />No</span> </td> </tr> </tbody> <tbody> <tr> <td>Remarks: <textarea cols="48" rows="4" name="remarksotherTEXT" runat="server" id="remarksotherTEXT"></textarea> </td> </tr> </tbody> <tbody> <tr> <td>Plan for next visit: <textarea cols="48" rows="4" name="POCnextvisitTEXT" runat="server" id="POCnextvisitTEXT"></textarea> </td> </tr> </tbody> <tbody> <tr> <td>Patient has wound: <input runat="server" id="patwoundyesTEXT" name="patwoundyesTEX
T" value="checkBox10" type="checkbox" />Yes <span><input runat="server" id="patwoundnoTEXT" name="patwoundnoTEXT" value="checkBox10" type="checkbox" />No</span> </td> </tr> </tbody> </table> </fieldset></div> </div>
#4, Look at the PDF created.
#5, Rendering to printer shows correctly.
Thanks!
MD