EL – Assisted Living Visit

This is a new patient a monthly follow up visit to review chronic conditions an episodic visit to address change of status a telephone encounter an email communication

HISTORIAN:

resident facility staff SO/family member complete history unobtainable d/t cognitive changes complete history unobtainable d/t HOH

NURSING:

unable to verify d/t cognitive changes none hospice HH

PLANNING:

unable to verify d/t cognitive changes full code DNR advanced directive on file no advanced directive POA

CURRENT MEDICATIONS:

administered by staff self-administered MAR available for review insulin BS log available for review warfarin INR results available for review opioids sedatives blood thinners/anticoagulants

IMMUNIZATION:

unable to verify d/t cognitive changes up to date not up to date declined per facility policy

FUNCTIONAL STATUS:

resident at assisted living facility lives at home requires assistance with most ADLs incontinent O2 use smoker hard of hearing

MOBILITY:

unable to verify d/t cognitive changes ambulates unassisted difficulty with mobility ambulation requires walker ambulation requires cane ambulation requires assist uses wheelchair uses motorized scooter/wheelchair

PATIENT/CAREGIVER/STAFF REPORTS:

INTERVAL HISTORY/CC:
patient complains concerns by staff concerns by family ER/UC visit hospitalization surgery/procedure diagnostic/laboratory studies specialty consults new medications infection falls wounds behavioral changes wt loss

ROS:
[+] reported
[-] not reported

CONSTITUTIONAL:

fever malaise fatigue deconditioning night sweats weakness wt loss
HEAD/FACE:

headache scalp swelling facial pain facial swelling facial numbness
EYES:

decrease in vision requires glasses for reading dryness irritation lid swelling discharge
EARS:

pain pressure discharge bleeding wax hearing loss ringing hearing aids
NOSE:

discharge PND congestion sinus pressure snoring bleeding
MOUTH:

sores dryness drooling tongue pain/swelling toothache infection odor swelling jaw pain clicking loose dentures
THROAT:

sore throat dysphagia choking hoarseness globus
NECK:

pain swelling limited motion swollen glands
CV:

chest pain/pressure SOB palpitations lightheartedness fainting exertional dyspnea orthopnea rapid wt gain ankle swelling ankle discoloration varicose veins leg cramps
Respiratory:

former smoker current smoker cough phlegm wheezing pain w/ breathing rib pain breast swelling/lump
GI:

constipation laxative use poor appetite nausea vomiting early satiety bloating heartburn gas generalized abdominal pain epigastric pain diarrhea melena rectal pain/itching rectal bleeding
GU:

dysuria burning frequency urgency odor hematuria hesitancy retention nocturia oliguria CKD discharge itching skin lesion(s)/rash
MSK:

joint pain/deformity neck pain back pain shoulder pain hip pain knee pain chronic pain/meds
NEURO:

dizziness vertigo poor balance abnormality of walk focal weakness blackouts tingling/numbness speech difficulty tremor seizures
PSYCH:

irritability confusion dysinhibition aggression withdrawal wandering repetitive activities suspiciousness depression apathy anxiety mood swings elation delusions hallucinations memory loss insomnia excessive naps
ENDO:

cold intolerance skin dryness hair loss polyuria
LYMPH/HEMA:

gland swelling bruising anticoagulation h/o DVT anemia
ALLERGIES/IMMUNE:

atopy environmental allergies food allergies autoimmune dz h/o cancer
DERM:

dryness pruritus rash hives redness swelling wounds

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Appearance:

well-appearing no signs of discomfort visible normal built clean-shaven good hygiene heavy built emaciated frail ill-appearing tired-looking short of breath diaphoretic slumped in wheelchair disheveled unshaven body odor
Head/Face:

normocephalic, atraumatic symmetrical face CN grossly intact alopecia facial droop
Eyes:

clear conjunctiva w/o exudates or hemorrhage, anicteric sclera, EOM intact without nystagmus visual acuity grossly intact red reflex present cornea(s) clear ptosis glasses periorbital swelling conjunctival injection epiphora conjunctival exudate palpebral edema palpebral exudates chemosis hyphema dysconjugate gaze
Ears:

symmetrical & intact auricles bilaterally hearing to conversation intact very HOH hearing aid(s) clear canals without erythema or discharge TMs normal in appearance large amount of wax
Nose:

nares patent bilaterally, no facial swelling or discoloration septum midline no facial tenderness mucosa pink & moist allergic salute maxillary tenderness frontal tenderness deviated septum swollen & boggy mucosa mucosal ulceration mucosal congestion clear discharge yellow discharge crusty discharge active septal hemorrhage dried up blood
Mouth:

tongue normal in appearance w/o lesions and with good symmetrical movements moist oral mucosa without lesions upper denture lower denture teeth absent some teeth present
Throat:

normal voice patent pharynx w/o swelling or exudates uvula midline clear pharynx w/o exudates pharyngeal erythema w/o exudates hoarseness vesicles on soft palate petechiae on soft palate pharyngeal crowding tonsilar exudates tonsilar pustules
Neck:

symmetric with free painless ROM and no masses supple no LAD no bruit or JVD thyroid enlargement nuchal tenderness
Lungs:

normal work of breathing, symmetrical chest expansion, no stridor clear and equal breath sounds bilaterally SOB decreased bilaterally wheezing crackles
CV:

regular rhythm no murmurs tachycardia irregular heart rhythm systolic murmur
Abdomen:

not examined normal visual inspection, no distension normal active bowel sounds soft non-tender no bruit auscultated over AA and renal arteries protruding surgical scar diffuse tenderness over entire abdomen w/o RRG umbilical hernia hypoactive bowel sounds hyperactive bowel sounds direct non-rebound tenderness colostomy in situ
GU:

not examined no suprapubic tenderness no smell of urine Foley in situ normal external genitalia
MSK:

no gross deformities, moves all extremities with good ROM for age kyphosis paraspinal muscle spasm
Upper extremity(s):

atraumatic w/o swelling or deformity good ROM for age equal power and tone bilaterally able to make tight grips no vascular compromise ecchymoses clubbing
Lower extremity(s):

atraumatic strength, tone & bulk symmetrical & grossly intact able to stand up no vascular compromise compartments soft w/o tension pedal skin warm with good & equal pulses no edema xerosis calf tenderness ankle edema varicosities loss of hair ecchymoses stasis discoloration varicose veins
Neuro:

balance & coordination grossly intact no involuntary movements normal speech sensation symmetrical & grossly intact full weight bearing wide gait shuffling gait tremor dystonia dyskinesia
Behavior:

pleasant, cooperative engaged withdrawn hostile defensive argumentative suspicious ingratiating demanding
Psych:

alert oriented to self and place appropriate to situation normal concentration and attention memory grossly intact good eye contact speech normal rate & rhythm organized thought process drowsy poor eye contact confused agitated anxious irritable indifferent guarded expansive affect flat affect labile affect speech slurred hypoverbal hyperverbal speech loud speech slow speech rapid tangential thought circumstantial thought aberrant thought flight of ideas poor judgment & insight
Skin:

grossly intact, no rashes no bruises normal turgor multiple tattoos body piercings poor turgor dry sweaty

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ORDERS:

none Rx electronic Rx paper left at facility Rx faxed to pharmacy laboratory studies diagnostic studies referrals

REVIEWED:

MAR chart previous visits PMP laboratory studies diagnostic studies specialty reports hospital discharge facility communication

DISCUSSED/COMMUNICATED FINDINGS/POC WITH:

patient staff family MA

PATIENT/SO/STAFF INSTRUCTED ON:

vital signs office tests exam findings recommendations outside laboratory/diagnostic studies specialty consults importance of controlling chronic conditions age-appropriate screening and immunization diet, exercise smoking cessation alcohol/substance use

ADVISED ON PREVENTATIVE CARE:
colonoscopy DEXA mammogram dental exam eye exam foot exam patient declined appropriate referrals to be generated

FOLLOW UP:

1 week 2 weeks 3 weeks 4 weeks discharged

TOTAL TIME:

15 min 30 min 45 min 60 min 75 min visit dominated by counseling

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Depression Screening:
over the past two weeks, have you felt down, depressed, or hopeless? over the past two weeks, have you felt little interest or pleasure in doing things? over the past 2 weeks, have you felt suicidal?

Patient/Caregiver Support:
do you feel unsafe at home? Do you live alone?

Functional Ability Screen (needs help with):
phone transportation shopping preparing meals housework laundry medications managing money

EL – Assisted Living Visit

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