This is a skilled nurse visit note. Okay so I went to my outbox pulled this up. Remember on every form you have to put a time in and time out before you can save it. So just make sure you do that. Visit date is cool thing about this too, so you can go back and view a previous note if you want, so you're not sure about last time you were there you can pull that up, and it will show you what you put in your last visit. And you can work off of that if you need to. You're going to go through, and you're going to fill out your systems like you normally would. Here's your knowledge, ability, and make sure you're clicking all the ones that you did in your started care capture. Your medication changes if there are any. As you go down and get into your goals and interventions, you don't need to enter the correct mileage. I don't know why that's why that keeps pulling up there. Goals and interventions so this will be your planning care that you created on your started care. If I want to document progress on this goal that's what I'm going to click. I performed all these patient and caregiver they were less understanding the reason we're having to do a little more work with the goals and interventions is Medicare wants to see each and every visit exactly what we're doing to support us being in there, so we have to speak to the goals that we've created for that individual plan of care and that we are doing the interventions that we said we were going to do to help the patient through the skilled service that they need. If you didn't perform one of these interventions then...
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Is able to eat. Dr. is attentive and caring. Patient has good appetite and has a positive attitude about her condition. Dr. ordered the catheterization. Patient has had very good results from her recent catheterization. Patient went to XXX. Dr. told him he was there on a respite, so he was in his office for an exam x 5 days. During the interview, Dr. asked Patient about his current medication. Dr. asked Patient if he was taking any other medications. Dr. told Patient that he would need to continue his dose of medication for his bladder disorder. Patient accepted that, and is continuing to take medication for his bladder disorder. Dr. instructed Patient to take 3,000 mg to 5,000 mg of Diluted per day for the first 4 weeks. Patients response was consistent with previous studies and is encouraging. Patient has noticed a decrease in his pain. Patient has been able to eat. Patient has a positive attitude about his current condition. Dr. is confident that this patient will have a good outcome. Patient is scheduled for follow up x 2 weeks. Dr. has asked Patient and other residents to meet with the resident on a regular basis to discuss issues. After 2 weeks, patient returns to the facility to complete a follow-up x 2 week. Dr. has continued to give Patient Diluted in 3,000 mg. In 2 weeks, patient has not had a single problem with his fluid intake x 2 weeks. After 3 weeks, Patient is able to eat 3 times after stopping Diluted. Patient has a positive attitude about his condition and continues Diluted in 4,500 mg each day. After 4 weeks. It is confirmed that patient will continue to take Diluted in 4,500 mg each day. Patient has continued to respond to Diluted without experiencing any side effects. In our experience, the diagnosis and treatment of a bladder in septic shock and a bladder in need of intervention is a challenging one. The bladder must be surgically examined for the diagnosis and treatment of this condition without risk to the patient. The diagnosis of the bladder in septic shock should be based on a clinical history including a history of acute urinary retention. A history of a urinary catheter removal and bladder dysfunction should be documented to determine the presence of an acute bladder abnormality requiring treatment. Patients with a history of urinary catheter removal or an acute bladder dysfunction need to be treated.
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