Asir Health Cluster

King Abdullah Hospital – Bisha

Home Healthcare

تجمع عسير الصحي

مستشفى الملك عبدالله بيشة

الرعاية الصحية المنزلية

Home Healthcare Nursing Assessment Note

Patient Information

Patient Name

MRN (Medical Record Number)

Document Type

Assessment Visit

Clinical Assessment

Vital Signs

Blood Pressure

/

Heart Rate

Resp. Rate

Temp (°C)

SpO₂ (%)

Blood Glucose

Pain Scale (0-10)

Vitals Status

Stable Unstable

Overall Patient Status

Improved Stable Declining New Complaint Other

Descriptive Notes

Focused Assessment

System Assessment

Wound Status

Improving No Change Worse New

Respiratory Status

Clear Congested Increased SOB

Mental Status

Alert Confused Lethargic

Additional Notes

Risk & Functional Status

Skin, Mobility, & Risk Scores

Fall Risk (Morse Scale)

Low Moderate High

Pressure Injury Risk (Braden Scale)

Severe High Moderate Mild No Risk

Skin Status

Intact At Risk Bruising Wound Present

Wound Description & Pressure Injury Staging

Stage 1 Stage 2 Stage 3 Stage 4 Unstageable Deep Tissue Injury (DTI)

Mobility

Independent Walker/Cane Wheelchair Bedbound

Transfers

Independent Supervision Needs Assist

Feeding

Independent Setup Help Needs Feeding

Toileting

Independent Assist Incontinent

Interventions & Plan of Care

Tasks Performed

Dressing Change Medication Admin Education IV Therapy Injection

Blood Draw ↗

Select Tests HbA1c Chemistry Hormones CBC Liver Function Kidney Function

Catheter Care ↗

Catheter Size (Fr) 12 14 16 18

NGT Placement ↗

NGT Size (Fr) 12 14 16 18

Vaccines ↗

Select Vaccine Influenza (1 dose) Shingles (2 doses) Meningococcal

Caregiver & Education

Caregiver Status

Engaged & Coping Stressed Needs Support

Understanding

Understands Well Needs Reinforcement

Education Topics Provided

Medications Wound Care Fall Prevention Nutrition Managing Supplies

Plan & Follow-up

Actions Taken Based on Assessment

Notified MD Re-education Provided Medication Adjusted

Future Plan

Continue Current Plan Modify Plan (per MD order) Schedule Follow-up Sooner Escalate to Specialist/ER

Plan Narrative

Quick Narratives

Vaccination

Patient Cooperation

Caregiver Cooperation

Overall Summary & Nurse's Notes

Nurse Name

Zuhur Al-Amri Rajaa Ayman Nasser Al-Qahtani Hamad Al-Qahtani Hinda Al-Shahrani Other