Free 02AG039E (AG-22) Instructions - Oklahoma

Personal Care Services Progress Notes Purpose of Form

02AG039E (AG-22)

Form 02AG039E is used by the long-term care (LTC) nurse to document visits made to the home of Personal Care clients for either the routine visit and/or for impromptu case management visits. Recertification visits are visits conducted to comply with established routine visits during which reassessments are also conducted. Instructions for Preparation of Form The form is divided into two sections. Both or either of the sections is completed as needed. The FOLLOW-UP VISIT section is completed during the regularly scheduled routine visits. These may be at any interval up to every 180 days. The CLIENT COMMUNICATION area of this section solicits the client's response about their care and services. The CASE MANAGEMENT section is completed when the nurse makes a visit that is in response to a client situation requiring the nurse's case management skills. ROUTINE VISIT. Nursing assessment: Health conditions: Are the health conditions the same since the previous assessment? Are there additional health problems? Medication concerns/changes: In review of the medications the client is taking, are there any nursing concerns? Are there any medications that have changed? Condition of skin: Describe skin condition, such as dry, scaly, reddened, oily, or normal. Peripheral edema: Describe amount of swelling using thumb print method. Location of site: Describe physical location of listed sites that are visible. Personal Care services. # authorized/week: Enter number of units/week approved and listed on client's Form MS-52, Medical Evaluation Report. Scheduled frequency of follow-up visit: Enter how often the LTC nurse will make service management visits, based on the needs of the client and the community potential rating. Teaching/instructions: Enter topic of health or safety issue and instructions provided to client. CASE MANAGEMENT VISIT: If the visit is a case management visit only, the nurse completes only the client name, case number, county, and LTC nurse signature and date at the top of page 1. Reason for visit: Check appropriate response. The LTC nurse documents the reason the visit was made. Issue/interventions: What was the problem? The LTC nurse documents the resolution of the problem. What was the LTC nurse's response to address or eliminate the problem? Note: If the visit was routine, and the LTC nurse is using pre-printed Form AG-22, the Case Management Visit section is crossed out and the nurse signs the form Routing of Form Original Copy Client file provider agency 1

OKDHS revised 1-1-2005