Single Visit Note Form

Date *

Patient Name *

Patient ID Number *

Height

Weight

Date of Birth *

Phone *

Location, Address of Visit *

Physician Name

Phone

Primary Diagnosis (Supports this Visit)

ICD-9

Date of Onset

Secondary Diagnosis

ICD-9

Date of Onset

Allergies

Physician's Order

Functional Limitations (Check all that apply)

Amputation	Dressing (Grooming)	Language	Bowel/Bladder Incontinence	Meal Preparation
Ability to Learn	Paralysis	Housekeeping	Nutritional Needs	Blindness
Contracture	No Limitations	Dyspnea	Hearing	Ambulation
Bathing	Speech	Telephone Use	Other

Temperature

O

A

R

E

Pulse

Radial

Apical

Respiration

Blood Pressure

History/Assessment Findings Relevant to Services Provided

Goal of Visit

Interventions/Actions

Outcome

Patient Tolerated Procedure

Yes

No

Goals Met

Yes

No

Patient/Caregiver Instructions

Patient's Rights	Disease	Procedure
Medication Information	Equipment Information	Other

Patient has advanced directives:

Yes

No

Patient instructed on advanced directives:

Yes

No

Patient/Caregiver independent in care:

Yes

No

Satisfaction return demo:

Yes

No

Patient/Caregiver verbalized understanding:

Yes

No

Referred to

I hereby authorize RX Team Home Health Care LLC to render appropriate home care services. I, certify that the employee arrived at am/pm, left at am/pm, and provided satisfactory care.

Employee Name/Title

Date

Physician's Name

Patient Name

Physician's Signature

Date

Patient's Signature

Date