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Visiting Nurse Details
Visit Date
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:
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Time Out
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AM
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AM/PM
Nurse Name
First
Last
Visit Type
Standard Visiting Nurse Visit
New Client Assessment
Re Assessment of Care Plan
Re Assessment After Hospitalization/​Rehab
Training /​ Education of Caregiver
Client Information
Name
First
Last
Primary Contact
Name
First
Last
Relation to Client
Phone
Vital Signs
Click Add Item to Enter The Vitals
Blood Pressure | Heart Rate (Pulse)| Respiratory Rate | Temperature | Oxygen Saturation (SpO₂) | Blood Glucose (if applicable) | Pain Level (0–10) | Weight (if ordered)
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Vital
Reading
Notes
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Primary Goals
Check all that Apply
Safety at Home
Maintain Independence
Companionship
Support with daily routines
Memory /​ Dementia Support
Family Peach of Mind
Comments /​ Notes:
Caregiver Personality Preference
Check all that Apply
Calm/​Patient
Engaging /​ Converstational
Quiet/​ Task-Focused
Dementia - Experienced
Physically Strong
Consistency Preferred
Comments /​ Notes:
Care Style Preference
Check all that Apply:
Structured Routine
Flexible Routine
Ask before assisting
Take initiative when appropriate
Comments /​ Notes:
Daily Routine Confirmation
Select all that Apply:
Preferred wake up time documented
Preferred bedtime documented
Meal preferences noted
Household rules reviewed
Pets present in home
Comments /​ Notes:
Non Medical Care Expectations
Client requests assistance with:
Bathing.hygiene (nonmedical)
Dressing/​grooming
Toileting assistanced
Tranfers/​mobility
Meal Prep/​ Hydration Matters
Light Housekeeping
Companionship
Errands /​ transportation
Dementia cueing /​ redirection
Comments /​ Notes:
Level of assistance needed
Stand by /​ cueing
Hands on Assist
Total assist
communication Preferences
Select all that Apply:
Caregiver communicated directly with client
Caregiver communicates with family
Office is primary communication contact
Update Frequency
As Needed
Weekly
Only if concerns arise
Comments /​ Notes:
Safety & Observation
Select all that Apply
Home environment appears safe
Fall Risk identified
Mobility limitations observed
Cognitive impairment noted
Nutrition /​Hydration concerns
Medication concerns
Comments /​ Notes:
Expectations Alignment
Select all that Apply
Current care plan meets expectation
Minor adjustments needed
Significant changes required
Office notified of care plan updates
Comments /​ Notes:
Medical Home Health Care Escalation
Observed or reported concerns requiring escalation.
Recent Hospitalization /​ ER
Wounds or skin breakdown
Third Choice Uncontrolled pain
Shortness of Breakth
Frequent calll
Medication Management
Rapid Physical or cognitive decline
Action taken:
No escalation needed
Recommend Medical Home Health Care
Office notified
Family informed
Emergency services recommended
Comments /​ Notes:
Caregiver Instruction and Coordination
Follow Up
Caregiver Instruction Documented
Updates coordinated with office
Follow Up visit Recommended
Comments /​ Notes:
Caregiver Instruction and Coordination
Follow Up
Care plan notes completed
Documentation entered in Bloom Homecare software
Visit ready for payroll sent to the office
Comments /​ Notes:
Visiting Nurse Signature
Signature
Today's Date
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Client Signature
Signature
Today's Date
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