Perfecting my SOC process.

Atownshend · Nov 26, 2014

So I'm trying to perfect my SOC process to shrink the time down in the home to make it most efficient. I want to minimize the time I spend being a questionnaire and maximize time for physical assessment and teaching. So I've come up with the following solutions. The first picture is the form I use for reminding me what to physically assess as well as information I get from the referral sheets. (Its printed on 1 x 2 pages so front and back are on top of each other.) It also has check boxes on the bottom reminding me to chart certain things I could easily forget on the profile page, etc... Then on the back of that one there is space for me to jot down their PMH, events leading to this admission, Goals, (both mine and theirs), my basic desired orders for when I call the md, and any issues that popped up on med recon to tell the doctor. This way when I call the md, everything is in the same place and I don't forget things like, "damn, I forgot to ask for a PT order!", or, "I forgot to tell her about that one med that wasn't on the list".

The second form is one that keeps track of open charts that have yet to be coded, or need PT visit numbers entered, or need a call back for orders...things that are rarely completed the day of. This way I'm not shuffling through papers to find out what's outstanding.

The last form, which I just cut and pasted on here, is a questionnaire I give the patient while I'm filling out their other forms with printed name/date/ etc... although I'm considering letting them fill these out and just highlight the areas I need from them because it takes time to do that I could be using to start their medication reconciliation.

Anyway I hand them the check form which is similar to what they would fill out as a new patient at a doctors office except it has all the question and answer parts of the Oasis. This way I just glance over the form when they are done and ask some follow up questions and most of my visit is done already! Just the med recon, forms and physical assessment and teaching left. Then I can put everything in the computer at my own leisure. It has shaved about 30 minutes off my visit time. But these things still take forever. What do you think?

Name__________________________Date of birth___________________Todays Date__________

If you are found to be a high fall risk, would you like physical therapy? Accept □ Decline □

What is your race/ethnicity?______________Do you have a living will? Yes □ No □

Who is your emergency contact?__________________Relation__________number_________

Is it ok to divulge your medical information to your emergency contact? Yes □ No □

Please list your drug allergies and what happens when you take them...

DrugReactionDrugReaction

______________________________________________________________________________________

What pharmacy do you use?__________________________________phone number_________

List your doctors and their specialties _________________________________________________

______________________________________________________________________________________

In the last 14 days have you had issues with the following? Check as appropriate.

□ Incontinence of urine □ Urinary Tract Infection □ Confusion

□ Incontinence of stool □ Impaired Decision Making □ Anxiety

□ Urinary Catheterization□ Severe Memory Impairment □ Decreased interest

□ Pain that wouldn't go away □ □ Depression

___________________________________________________________________________________________Do you receive IV therapy at home? Yes □ No □

Do you get fed through a feeding tube? Yes □ No □

Do you smoke? Yes □ No □ How many alcoholic beverages do you drink a week?________

Who is your primary caregiver and their relation?__________________________

What is your religion?________________ Height _____________ Weight__________

Do you have any of the following symptoms currently?

□ Dizziness □ Numbness/Tingling □ Tremors □ Short Term Memory Loss

□ Fatigue □ Chest pain □ Leg cramps |□ Long Term Memory Loss

□ Palpitations□ Shortness of Breath □ Cough |□ Arthritis

□ Gout □ Weakness □ Stiffness □ Decreased range of motion

_________________________________________________________________________________________

Check as appropriate:YesYes

Do you wear glasses? □ Do you wear contact lenses? □

Do you have Glaucoma? □Cataracts? □

Hearing Aids?□Hard of hearing?□

Partial Dentures?□Full Dentures?□

Missing Teeth?□Do you use Oxygen at home?□ How many

Sleep apnea?□Cpap or Bipap?□ liters?____

Do you have pain? Yes □ No □ If yes, where?____________________________________________

When did the pain start?_________________What makes it worse?______________________

Is it worse during the day or night?____________ How long does the pain last?_____________

On a scale from 0-10, zero being no pain and 10 being the worst pain you've ever had in your life, what is the worst and best your pain gets? Worst________Best________

Describe the pain, ie throbbing, aching, burning, sharp, dull, discomfort?____________________ What does the pain prevent you from doing?_______________________

What do you do to relieve the pain?_________________Does the pain radiate? Yes □ No □

Is your doctor aware of your pain?____________

Do you have pain in another location? Please describe_______________________________

____________________________________________________________________________________

Name_________________________________________________

Do you eat at least 1/2 of your meals? Yes □ No □

Do you have any open wounds? Please describe type and location__________________

_______________________________________________________________________________

Do you have a history of pressure ulcers/bedsores? If so where on your body were they?_______________________________________________________________________________________

Do you currently have the following when you urinate? □ Burning □ Frequency □ Urgency

Do you occasionally leak urine i.e... when you laugh or sneeze? □ Yes

If you do have incontinence or leaking, check the following:

□ It is a problem day and night. □ It is worse during the day. □ It is worse at night.

□ If I go to the bathroom at regular intervals I do not have a problem.

When was your last bowl movement? Today □ Yesterday □ Other__________________

Are you on a sodium restricted, diabetic or other special diet?_____________________________

Have you lost 10 pounds involuntarily in the last 6 months? Yes □ No □

How many falls have you had in the last year? ____ How many in the last 3 months?______

In the last 2 years have you had the following tests? Check as applicable.

□ Cholesterol blood test Women OnlyMen Only

□ Colonoscopy □ Papsmear □ PSA blood test

□ Rectal exam □ Mammogram

□ PPD Tuberculosis screen

□ Chest X-Ray

Please check all the equipment below that you currently own.

□ Standard Cane □ Hospital bed □ Dressing Stick

□ 4 point Cane □ Trapeze □ Reacher

□ Standard walker□ Raised Toilet seat□ Lap Tray

□ wheeled walker□ Bedside Commode □ Special Eating Equipment

□ Walker basket □ Bathroom Grab bars □ Splint

□ Chair lift□ Handheld showerhead □ Gait Belt

□ Wheelchair□ Long Bath sponge/brush □ Shower chair

□ Transfer Board □ Long shoe horn □ Tub transfer

□ Hoyer lift □ Sock aid

Is there any medical equpment that you do not own but rent? Please list______________

____________________________________________________________________________________

Last flu vaccine day______ month_______year_________unknown □ refused □

Last pneumonia vaccine day_______month__________year_______ unknown □ refused □

Are you diabetic? Yes □ No □ Todays blood sugar?__________ Your blood sugar range?_____

Have you been admitted to the hospital more than once in the last year? Yes □ No □

When is your followup appointment with your doctor(s)?_______________________________________________________________________________________