1.

Vital Signs
 Temp  SPO2/O2

 BP  HR

 Pain  RR

 Non-Pharm Interventions

2. ADL status? Independent/Supervision/Limited Assist/Extensive Assist/Total Care and # of Staff Support

 Bed Mobility: I/S/LA/EA/TC # of staff  Eating: I/S/LA/EA/TC # of staff

 Transfer: I/S/LA/EA/TC # of staff  Toileting: I/S/LA/EA/TC # of staff
3. Cognition status  Shape of abdomen
 Alert  Soft or hard
 Oriented x  Tender or non-tender
 Coma/Disorientation  Continent/Incontinent/Ostomy Care
4. Ability to communicate  BM Yes/No
 Aphasic
 Hearing Problems 9. Skin
 Problem making needs known  Surgical Wound Care/Treatment Done
5. Cardiopulmonary  Pressure Injury (Stage )/Treatment Done
 Lung Sounds (clear, diminished, crackles,  Arterial or Venus Ulcer/Treatment Done
wheezes, rhonchi, or pleural rubs)  Skin Tear/Abrasion/Treatment Done
 Suctioning 10. Behavior
 Productive or Non-Productive Cough  Wandering (wander-guard)
 Shortness of Breath  Verbally inappropriate
 Nebulizer Treatments  Physically inappropriate
6. Nutrition  Resistant to care
 Diet (regular/mechanical soft/pureed)  Hallucinations
 Thickened Liquids (nectar/honey)  Delusions
 Fluid restrictions  Family aware of any changes?
 Tube Feeding 11. Musculoskeletal
 Emesis #  Unsteady gait
 Weight loss or gain  Hemiplegia
7. Urinary  Fracture/site
 Foley (Fr #)/Supra-Pubic/Care Complete
 Amount  Non-Weight Bearing
 Color of urine  Amputation/Site
 Clarity
 Continent or incontinent 12. Were injections given? IV? IM?
8. Gastrointestinal
 Bowel Sounds
MEDICARE A NOTES
  Flu/PNE/Diabetic/Blood Thinner/IV Fluids/IV
Abts/Other

13. New physician’s orders: note the order/MD, was it

transcribed, faxed, and endorsed?
14. Did the resident participate in therapy
(PT/OT/ST)?
15. Did the resident participate in RNP (ROM/Splint
Care/ Ambulation/Scheduled Toileting)?
16. Patient or Family Teaching Done? What?

MEDICARE A NOTES