Sample Note

Prepared by: Modesto R. Moreno
Organization: Vertex Visionary Labs
Contact Information: 222 555 7777, [email protected]
Address: 128 Innovation Boulevard, Raleigh, NC 27606, USA
Company Email: [email protected]

Resident Information

Benjamin C. Spencer, an 86-year-old Caucasian male, with a history of hypertension and recent mild stroke. He has been admitted today to our Nursing Home.

Medical History

During his admission, Benjamin was alert and oriented, with stable vitals. His primary diagnosis is Hypertension and secondary is a mild stroke. His current medications include Lisinopril and baby Aspirin.

Nursing Diagnosis

Based on the initial assessment and family interview, Ben seems to have issues with performing daily living activities independently due to stroke weaknesses. A higher level of care will be required to ensure his safety and well-being.

Plan of Care

Ben will be assigned to our skilled nursing care program where he will get assistance for his daily activities. Physical therapy sessions will be included in his daily routine to improve his mobility. His blood pressure will be monitored regularly and medications administrated timely.

Expected Outcomes

With a progressively attentive and therapeutic environment, we expect Ben to experience improvements in his current health state and enhance his ability to perform activities of daily living.

Discussions

Discussions have been held with the resident and his family. They have been briefed about the admission note and plan of care. They were allowed to express their concerns and those were addressed adequately.

This admission note has been prepared with utmost precision to deliver quality care to our resident. For any further clarification, please do not hesitate to contact the undersigned.

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