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Metadata service for discovering, understanding, and managing data. Service for securely and efficiently exchanging data analytics assets. James Doe visits today because of worsening bilateral knee pain.
The patient has had an orthopedic evaluation for severe osteoarthritis but is not a candidate for surgery at this time due to his worsening pulmonary disease. He has been taking the prescribed nonsteroidal anti-inflammatory medication without relief and continues to have difficulty with ambulation and climbing stairs.
Patient requires physical therapy and occupational therapy evaluations and requires an assistive device for safety with all ambulation. This patient is declared homebound due to recent falls secondary to severe debilitating chronic osteoarthritis causing an unsteady gait, and need for assistive device when ambulating.
Electronically signed by M. Jones 22 National Government Services, Inc. Balance is poor-requiring use of a walker. She is homebound due to these issues. X-rays of her left hip and shoulder are normal but there is significant bruising and abrasions.
Disoriented to time with short-term memory loss noted. Breath sounds clear, no cough. Abdomen soft with active bowel sounds. All pulses present.
No pedal edema noted. Patient is legally blind and requires assistance to leave home. A PT evaluation was done as well as gait training with a cane. Patient is very hesitant to use a cane. The patient will benefit from additional gait training for safety. Need for a cane and blindness results in her being homebound. I informed the home health agency that you will be the physician approving the plan of care. She is currently homebound with a new walker for her unsteady gait and requires training and education with her assistive device and insulin therapy.
Clinical information: Nursing services are required for this 42 year old wheelchair bound paraplegic male patient to include wound care of infected stage 4 sacral decubitus ulcer. Prescription medication for dressing change requirements provided. Clinical condition- Pernicious anemia, chronic bronchitis.
Requires nursing services for vitamin B12 injections and assessment and education about her illnesses. Electronically signed by N. Note: This form is missing a title and the homebound status description is very vague, NGS says.
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