Nursing Home Rounds

NURSING HOME ROUNDS

a summary of areas to cover for periodic or annual evaluations

( for extrapolation see Nursing home article in syllabus)
VISIT TYPE
ACTIVITY / Periodic (Regula-tory) / Annual
Chief complaints:* / + / +
Review of past active problems:* / + /

Cover all problems

Functional status  / +
Surgical hx. / +
Medications “ R,R& R”** / + / +
Allergies / +
Social history / +
Family/POA contact / (as
indic-ated by change of cond-ition) / +
Advance directives / +
Immunizations / +
Nutrition(wt) / + / +
ROS: vision / +
hearing / +
dentition / +
cardiac / (as indic-ated by change of condition) / +
resp / (as indic-ated by change of condition) / +
BOWELS / + / +
BLADDER / + / +
MUSC-SKEL / (as indic-ated by change of condition) / +
SKIN! (“SORES”) / +
neuro / (as indic-ated by change of condition) / +
mental status / + / +
mood / + / +
BEHAVIOR)*** / + / +
PHYSICAL EXAM
problem focused / +
complete / +
REVIEW & SIGN-OFF
f/u therapies, labs, consults / + / +
verbal/telephone orders / + / +
document on each resident*# / + / +
address each problem: status, rehab & plans / +
*source: see doctor’s list on floor &/or contact charge nurse then see resident.
ADLS: mnemonicD-E-A-T-HDress,Eat, Ambulate, T ransfer, H ygiene)
**Meds: ( Review, Reduce & Remove): look for
medication reduction possibilities set reduction
schedule, write parameters for call back or follow
up.
*** “targeted behavior” management follow-up. (see behav. monitor sheets on wings)
! SKIN: “SORES” Sensory loss, Ooze (moisture), Restricted, Eat, Shear
*# see (“Periodic and New & Annual exam format on opposite side) evv 4-04-04

Regulatory (Periodic) Visits

-Review Chief complaint and Past Active Problems

(Using a “Soap” foremat)

Be sure to address:

-Medications (“Review, Reduce and Renew”)

-Bowel and Bladder

-Mental status and behavior (if applicable)

-Nutrition

-Skin (if at risk)

(See NH Rounds sheet)

*************************************

Initial and Annual Exam

REASON for ADMISSION: age, date of admission, race,

CHRONIC ILLNESS REVIEW:

(Review each medical problem over last year re:

- change in status

- hospitalizations & tests

- therapies (P.T., OT, Psych.etc)

-current status

FUNCTIONAL STATUS:

(ADLS: (ie) ability to:

(Dress,Eat, Ambulate, T ransfer, H ygiene)

SURGICAL HX.:

MEDICATIONS

ALLERGIES

SOCIAL HX.

(Comment on status of:

loneliness, helplessness,& boredom)

ADVANCE DIRECTIVES/POAHC

IMMUNIZATIONS (include TB screening)

NUTRITION

ROS (cover items not covered above)

PE ;

( inadditionto usual physical exam,

also comment on these items):

GENERAL

-weight -nutritional status

ENT

-speech -teeth -hearing

-vision -mobility of neck

MSK:

-ROM -mobility -posture

-function of UE & LE

-assistive devices

SKIN

-pressure ulcer risk & current status

NEURO

-mental status -mood -behavior

-Capacity to make medical decisions

IMPRESSIONS/PLANS:

(for each problem comment on plan,

where relevant comment on:

-Rehabilitation potential & plans to accomplish

evv4-8-04