Each Visit Note has standard pages included. These pages are:
● First Page:
o Vital Signs
o Pain
o Blood Sugar
o Oxygen
o Allergy Information
● Last Four Pages:
o Process Measures; Assess/Teach/Perform for Comorbidities/Additional Diagnosis
o Wound Page
o Assessment Summary; Goals
o Homebound Status, Progress toward Nursing Goals, Plan for Next Visit, Discharge Planning and Care Coordination Page.
o Page 2 and sometimes continued onto Page 3 of the Disease Specific Notes will contain the specific disease items for each note. The areas included on these Disease Specific pages are: Visit Goals, Assess and Teach (Areas specific to the disease), Perform (Clinician to add below per patient plan of care)