Home Care

Home Health Story Board

Sharon a home health nurse arrives at valeries home. Valerie is a sixty seven year old female who is in need of assistance from a skilled nurse to help in her rehabilitation efforts after suffering from a minor stroke. Sharon takes a few minutes to introduce herself and get to know Valerie. Sharon also came prepared with a static care plan that was created for Valerie when she was an inpatient in the hospital. Sharon pulls up this static care plan on her laptop as a reference as she visits with Valerie and discusses the prior care given to Valerie and to help analyse appropriate care in the future. Sharon is able to see the platelet inhibitor and cholesterol reducing meds that Valerie was discharged on. Sharon asks Valerie if she has any questions regarding the medications or any discharge orders that she was sent home with. Sharon also performs a quick assessment including a basic set of vital signs and documents this in the appropriate area on the care plan. As Sharon and Valerie talk about rehabilitation efforts one of the goals that Valerie would like to work on is managing her weight. Sharon documents this along with a set of realistic interventions and steps on weight management. As Sharon leaves this home health visit she reminds Valerie of the goals they discussed and the time of the next visit. A few times a week Sharon stops by her office and is able to dock her laptop and upload her patients care plans to the EHR. During Sharon’s subsequent visist to Valerie Sharon is able to reference the care plan and update assessments and progress. Valerie is scheduled to meet with her primary care provider on a monthly basis to assess her health and prevent future complications. Today is Valeries first visit to Dr. Primary Care since her minor stroke occurrence. However, Valerie has already met with Sharon her home care nurse four times already. Dr. Primary Care accesses Valeries care plan and reviews the assessments and progress made over the last four weeks. Dr. Primary Care notices that one of Valeries goals is weight management. Dr. Primary Care congratulates Valerie on her weight loss over the last four weeks and also discusses the advantages of diet along with her exercise. With Valerie’s approval Dr. Primary Care schedules an appointment with a registered dietician to consult on diet along with her exercise. After Valerie leaves the visit Dr. Primary Care takes a few minutes to update the care plan and dictates progress notes. A week after Valerie met with Dr. Primary Care, Sharon the home health nurse visit Valerie. Sharon again access the care plan and reviews the updates and progress notes of the appointment with Dr. Primary Care. Sharon notices that Dr. Primary Care advised Valerie to consult with a Dietician and asks Valerie is she needs any help scheduling that appointment.