Sample Skilled Notes

Cardiovascular Compromise Assessment:

• Assessment Date: [Insert Date]
• Symptoms Noted: Shortness of breath, elevated blood pressure.
• Interventions: Notified physician, initiated oxygen therapy at 2L/min per nasal cannula. Vital signs monitored every 4 hours. Elevated legs to reduce edema.

Gastrointestinal Complication Monitoring:

• Monitoring Period: [Specify Duration]
• Symptoms Monitored: Abdominal pain, changes in bowel habits, vomiting.
• Observations: No episodes of vomiting or changes in stool consistency noted. Abdominal discomfort reported as occasional and mild.

Dehydration/Malnutrition Evaluation:

• Assessment Tools Used: Biochemical markers, dietary assessments.
• Findings: Mild dehydration noted (slightly decreased urine output). Nutritionist consulted for modified diet plan to address low calorie intake.

Circulation Problems Assessment:

• Assessment Focus: Peripheral pulses, skin temperature, capillary refill.
• Observations: Diminished capillary refill in fingers. Consulted vascular specialist for further evaluation due to cold extremities.

Isolation Monitoring:

• Isolation Reason: [Specify Reason]
• Compliance: Patient educated on isolation precautions (contact, droplet, airborne). Adequate understanding observed during educational session.

Hemodialysis Details (if applicable):

• Hemodialysis Session: [Specify Date/Time]
• Session Details: Hemodialysis conducted for 3 hours. Vital signs monitored pre/post-session. No complications reported during or after treatment.

Medically Unstable Condition Assessment:

• Clinical Indicators: Rapid heart rate, altered mental status.
• Actions Taken: Notified physician immediately, initiated continuous cardiac monitoring, increased oxygen supplementation to maintain SpO2 >95%.

Gastrointestinal Evaluation:

• Symptoms Assessed: Nausea, vomiting, abdominal pain.
• Observations: Reported decreased appetite, no episodes of nausea or vomiting. Abdominal pain rated at 2/10 on pain scale.

Diabetes and Insulin Management:

• Blood Glucose Monitoring: Regular finger-stick monitoring.
• Insulin Administration: Regular insulin (Humulin R) administered before meals as prescribed. No episodes of hypoglycemia reported.

Injections and Catheterization Monitoring:

• Injections: Administered intramuscular injection (IM) of [Specify Medication].
• Catheterization: Straight catheterization performed. Urinary output measured and recorded. No signs of discomfort or urinary retention noted.

These sample notes illustrate how assessments and interventions can be documented in a Medicare charting guideline. Adapt and modify them according to the patient's condition and specific clinical requirements.