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Home Bound Status
N/A
Bed Bound
Assist 1-2 Person
Restricted Activity
Not Home Bound |
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Vital
Signs
BP Left | Right
Lying
Sitting
Standing
Temp WT
AP HT
RP
RR |
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IV Therapy Status |
|
Medication _______________
Dose _______________
Frequency
_______________
Duration _______________
Lab Orders
N/A
Test _______________
Frequency
|
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Knowledge of Diagnosis
Patient
123
PCGN/A
123
Knowledge of Treatment
Patient
123
PCGN/A
123 |
|
Knowledge of Home Care Services
Patient
123
PCGN/A
123
Knowledge of Community Resources
Patient 123
PCGN/A
123 |