Progress notes reflecting skilled interventions following plan of care
Intermittent Nursing Visit documentation
Travel/Time Log completed and turned in per agency policy
Updates plan of care
Other :
Patient safety issues and means to maintain a safe home environment
Review and discussion of medications and teaching of side effects
Teaches safe use of equipment
Treatments and care procedures are taught and explained
Cardiopulmonary System
Respiratory System
Gastrointestinal System
Genitourinary System
Head, Eyes, Ears, Nose & Throat
Neurological System
Psychological
Endocrine
Integumentary System
Comfort/Pain Level
ADLs/Environment/Social
Medication Profile
Nutritional Profile
Plan of Care development and changes to plan of care (HCFA 485)
Observations and clinical changes
Obtaining verbal orders
Changes in plan of care or significant changes in patient’s condition
Durable Medical Equipment/supplies
Pharmaceutical supplies (Medications)
Access to other resources through referral to other team members or community programs relative to client’s needs
Registered Nurse
Physical Therapist
Occupational Therapist
Medical Social Worker
Speech-Language Pathologist
Home Health Aide
Other: (identify) :
Performs teaching to client/family/home health aide
Administers medications as required
Performs teaching to patient/family
Maintains Client Confidentiality
Conducts self in a professional manner
Reports to Supervisor as needed and appropriate
Maintains OSHA Guidelines for Bloodborne Pathogens
Participates in interdisciplinary conferences as requested
Coordinates patient care with RN for an average caseload of 20-25 patients
Understands all aspects of patient care oversight from scheduling to physician calls
Maintains a standard productivity of 25-35 visits per week as a full-time LPN
Understands when to call RN for support and assistance regarding care
All patient paperwork including visit notes and orders are accurate, complete and written at time of service provision or immediately thereafter and turned into agency within 24 hours of service/visit completion.
My signature below does not imply my agreement with the content of this evaluation, but that the above evaluation has been reviewed with me.