Flexible

We make it simple and hassle free to get started. Have an urgent need, we can start today. We can review all your documents or you can hand select what we review. Have special review needs or items you require in your documentation, no problem, we can taylor our reviews to your needs. Pay by the document, this way you are not paying for any wasted time.

  Teamwork

We understand the importance of your staff buying into the QA process. All of our return corrections are courteous and well-written so the errors are easily understood to make the corrections quick and simple. Our corrections are written the exact same way every time so your staff can quickly identify the correction requested. We inform your management of common mistakes in your documentation to help educate the staff on proper documentation.

  Accuracy

In addition to the M-questions and coding, we review all assessment items so that documentation is consistent and supportive for surveys and ADR's. We also check that best-practices are being followed so that your agencies star rating will recieve high grades. If your staff is not following best practices we work with your managers on ways to improve your processes and documentation to help improve your rating.


QA+. Software designed by QA experts.

Designed for accuracy, compliance and speed. Spend less time on quality assurance and get better results. Empower your staff with our tools. Very affordable at $350 per month.


QA+. Instant QA at the click of a button.

Seemlessly integrates withnin your EMR. No set-up time required. Get started in less than 2 minutes.

Quickly identify all documentation errors and see them side-by-side with the ability to correct them on the fly (great for the documenting nurse).  

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In addition to finding several hundred errors automatically, it allows you to quickly view all relevant assessment data in one central location. It highlights key words in the narrative and comments such as medications and vital signs. Gives you access to several hundred additional pre-written errors so your staff will never have to write out thier own errors again (great for consistency and speed). All errors indicate the pages where the corrections occur for quicker corrections. "Correct" mode allows you to correct the errors during the review process without having to change pages.


In addition to being a reviewer, it has several other tools to perform QA task. Such as it contains hundreds of templates that it will automatically create need-based 485's (based on patient diagnosis and assessment answers). Quickly compare diagnosis codes on Recerts / ROC to the previous OASIS. Pre-fill the first visit in the episode based on the OASIS. View all episode comments in an easy to read report. Plus Much More!


Click to Chat to discuss any questions, request a demo, or get signed up today. Start using our software within minutes. Seemless and easy to use.


Outsource to Us. Don't put your documentation at risk.

Instantly upgrade your documentation by outsourcing to QA experts. We stay up to date with Medicare guidelines and best pracitces. Our clients have gone through hundreds of surveys over the years and we pass that knowledge to you.

Outsource

Get started today and let us handle the hassle of QA for you!

We make the on-boarding process simple. We have a simple contract that requires no long-term comittment. Whether you want to use us as a temporary gap while your staff is on vacation or use us for a permanent solution for your QA needs. If you have been neglecting QA, it has never been easier to improve you documentation. Most documents have a turn-around time of less than 24 hours.

Click to Chat to discuss any questions or get signed up today!

Pricing Chart
ItemCost
QA+ Software (Per Agnency Per Month) $$350.00
Teaching Templates* $$325.00
Orders & Goals Templates* $$300.00
SOC / ROC / Recert $40.00
Discharge$40.00
SN Assessment$25.00
Plan Of Care Creation$7.00
Therapy Evaluations / Re-Evaluations$5.00
Skilled Nurse Notes$3.00
Therapy Notes$3.00
HHA Notes$1.00
Chat With Us For Any Documents Not Listed
*Will upload into your current EMR or make available for offline use (if EMR doesn't support template upload).

Templates... To make your staff's life easier.

We have hundreds of order and goal templates and thousands of teaching templates. See the lists on the left for topics and examples of our templates.

How do they work?

We upload them into your EMR (must have an EMR that supports templates and template uploads, ie Kinnser). When creating a plan of care, assessment, or routine visit note, you will have a dropdown with all the different template titles. When selected, it will prefill the corresponding field (ie narrative for an assessment) with the actual template text. Pefect for maintaining consistency for orders and goals in the POC and can act as a guide for items to instruct the patient on for specific diagnosis and orders.

What if I am unhappy with the templates?

We offer a 30 day satisfaction gaurantee. If you are unhappy with the templates we will refund you the total price of the templates as long as you allow us to delete them from your system.

How much do they cost?

The teaching templates are $325 and the order & goal templates are $300; $625 for all sets of templates.



  • *VS ALL PATIENTS
  • *Home Health Aide
  • *POC ALL PATIENTS
  • Abcess
  • Aftercare Following Fracture
  • Aftercare Following Hip Joint Replacement
  • Aftercare Following Knee Joint Replacement
  • Amyotrophic lateral sclerosis (ALS)
  • Alzheimer's disease
  • Anemia
  • Aneurysm
  • Angina
  • Angioedema (Angioneurotic edema)
  • Asthma
  • Atherosclerosis
  • Atrial Fibrillation
  • Atrial Fibrillation w/ PT/INR
  • Benign Prostatic Hyperplasia (BPH)
  • Bipolar Disorder
  • Bronchiectasis
  • Bronchitis
  • Malignant Neoplasm of the Colon
  • Malignant Neoplasm of Lung/Bronchus
  • Malignant Neoplasm of the Rectum
  • Cardiomyopathy
  • Cataracts
  • Cauda Equina
  • Cerebral palsy
  • Cellulitis
  • Cervical Spondylosis
  • Cervical Spondylitis
  • Cholecystitis
  • Choleithiasis (gall stones)
  • Chronic Obstructive Asthma
  • Chronic Obstructive Bronchitis
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Chrons disease
  • Cirrhosis of Liver
  • Colitis
  • Congestive Heart Failure (Primary)
  • Conjunctivitis
  • Coronary Artery Disease (CAD)
  • CVA/TIA
  • Deep Vein Thrombosis (DVT)
  • Degenerative Cervical Disc Disease
  • Dementia
  • Depression
  • Diabetes (Primary)
  • Diabetes (Secondary)
  • Diabetes w/ Neuropathy (Primary)
  • Diabetic Ulcer
  • Diverticulitis
  • Dysphagia
  • Eczema
  • Edema
  • Emphysema
  • Encephalopathy
  • Erectile Dysfunction
  • Fibromyalgia
  • Foley Catheter
  • Gastritis
  • Generalized Muscle weakness
  • Gastroesophageal reflux disease (GERD)
  • Glaucoma
  • GI bleeding
  • Goiter
  • Gout
  • Gouty Arthritis
  • H-pylori
  • Head injuries
  • Hematuria
  • Hemorrhoids
  • Hernia
  • Herpes
  • Human immunodeficiency virus (HIV)
  • Hyperkalemia
  • Hyperlipidemia
  • Hypernatremia
  • Hyperparathyroidism
  • Hypertension
  • Hypertensive Chronic Kidney Disease
  • Hyperthyroidism
  • Hypotension
  • Hypothyroidism
  • Hypovolemia
  • Idiopathic scoliosis
  • Insomnia
  • Insulin Administration By SN
  • Insulin Preparation By SN
  • Kidney Infection (Pyelonephritis)
  • Laryngitis/Pharyngitis
  • Late Effects of CVA Hemiplegia
  • Late Effects/CVA Fluency
  • Lumbar Intervertebral Disc Disease
  • Lumbosacral Spondylosis
  • Macular Degeneration
  • Meniere's disease
  • Multiple Sclerosis (MS)
  • Muscle Weakness
  • Muscular Dystrophy
  • Myelodysplastic syndrome
  • Myocardial Infarction (MI)
  • Nebulizer/Inhaler
  • Neuritis
  • Nutrition
  • Obesity
  • Open Reduction, Internal Fixation (ORIF)
  • Osteoarthritis (w/therapy)
  • Osteoarthritis (w/o therapy)
  • Osteomyelitis
  • Osteoporosis
  • Ostomy (Colostomy/ileostomy)
  • Ostomy w/ sutures
  • Oxygen Safety
  • Oxygen Saturation
  • Oxygen Saturation PRN
  • Pacemaker
  • Paget's disease
  • Pancreatitis
  • Paralysis
  • Parkinson's Disease
  • Percutaneous endoscopic gastrostomy (PEG)
  • Peripheral Neuropathy
  • Peripheral vascular disease (PVD) 01
  • Peripheral vascular disease (PVD) 02
  • Pernicious Anemia
  • PICC line
  • PleurX catheter
  • Pneumonia
  • Polycythemia Vera
  • Pressure Ulcer
  • Pressure Ulcer Prevention
  • Psoriasis
  • Pulmonary Embolism
  • Pulmonry Fibrosis
  • Quadraplegia
  • Restless Leg Syndrome (RLS)
  • Rhabdomyolysis
  • Rheumatoid Arthritis
  • Sarcoidosis
  • Schizophrenia
  • Seizure
  • Self- catheterization
  • Septicemia
  • Shortness of Breath
  • Sinusitis
  • Sleep Apnea
  • Smoking Cessation
  • Spinal Chord Injury
  • Spinal Stenosis
  • Steroid Use
  • Suction
  • Suprapubic Cystostomy catheter
  • Stiff Man Syndrome
  • Thalassemia
  • Tonsillar Fossa Malignancy
  • Tracheostomy
  • Transient Ischemic Attack (TIA)
  • Vertigo
  • Urinary Retention
  • Urinary Tract Infection (UTI) related to indwelling Catheter (Primary)
  • Urinary Tract Infection (UTI)
  • Venous Insufficiency
  • Venous stasis ulcer
  • Vitamin D Deficiency
  • Von Willeberg Disease
  • Wound Care
  • Wound Assessment
  • Wound Vac


Select an Order from the dropdown to see example "order" template text!

-SN to instruct Pt/Cg on ____ including s/s of exacerbation, complications necessitating medical attention, associated care/treatment & when to notify MD

-SN to instruct Pt/Cg on pain relief measures to reduce pain

-SN to instruct Pt/Cg on fall precautions & prevention

-SN to instruct Pt/Cg on medications including dosage, route, frequency, indications, & side effects

-May accept orders from consulting physicians./-DC Summary available upon request

-SN to assess musculoskeletal status; report to MD s/s of complications r/t Fractures: Deep Vein Thrombosis (DVT), decreased mobility & endurance, activity intolerance, problems w/ ambulation & transfer, increasing weakness, pain/numbness in extremity & edema; Assess ineffectiveness of pain medication

-SN to instruct Pt/Cg on Aftercare Following Fracture of ____ including s/s of exacerbation, complications necessitating medical attention, associated care/treatment & when to notify MD

-SN to assess musculoskeletal status & report to MD exacerbation/complications r/t Cervical Spondylosis; ineffectiveness of pain medications

-SN to instruct Pt/Cg on Cervical Spondylosis including s/s of exacerbation, complications necessitating medical attention, associated care/treatment & when to notify MD

-SN to assess Respiratory status, lungs for adventitious sounds; report to MD s/s of Chronic Obstructive Asthma exacerbation: wheezing, coarse rhonchi, diminished breath sounds paroxysmal coughing, increased sputum production, SOB, dyspnea on exertion

-SN to instruct Pt/Cg on Chronic Obstructive Asthma including s/s of exacerbation, complications necessitating medical attention, associated care/treatment & when to notify MD

-SN to instruct Pt/Cg on ways to improve respiratory status; factors that contribute to SOB; pursed lip breathing techniques; methods to recognize & relieve complications of pulmonary dysfunction

-SN to assess GI status & report to MD exacerbation/complications of Liver Cirrhosis; ascites, dyspepsia, change in bowel pattern, bleeding tendencies dilated veins around umbilicus, change in mentation, jaundice

-SN to instruct Pt/Cg on Cirrhosis of Liver including s/s of exacerbation, complications necessitating medical attention, associated care/treatment & when to notify MD

-SN to assess CP, CV status & report to MD s/s of Congestive Heart Failure (CHF) exacerbation/complications: increased SOB, increased edema, distended neck veins, lungs sounds w/crackles/rales, persistent coughing/wheezing, increased HR, increased fatigue/weakness, confusion, unexplained weight gain or decreased appetite

-SN to instruct Pt/Cg on Congestive Heart Failure (CHF) including s/s of exacerbation, complications necessitating medical attention, associated care/treatment & when to notify MD

-SN to obtain FBS/RBS level; notify MD of RBS >260 mg/dl or < 60mg/dl FBS >200 mg/dl or < 60 mg/dl

-SN to assess endocrine status; report to MD elevated/decreased blood glucose, s/s of hypo/hyperglycemia, ineffectiveness of medications & diet noncompliance, assess BLE/feet; report to MD skin lesions/wounds

-SN to instruct Pt/Cg on s/s of elevated/decreased blood glucose, blood glucose testing/monitoring/machine calibration, care of skin/feet

-SN to instruct Pt/Cg on Diabetes including s/s of exacerbation, complications necessitating medical attention, associated care/treatment & when to notify MD

-SN to notify MD for Edema 3+ pitting; lung sounds w/ rales, crackles & increasing SOB

-SN to instruct Pt/Cg on measures to prevent/treat Edema

-SN to assess CV status report to MD elevated BP, HR & rhythm; s/s of Hypertension exacerbation; elevated BP, severe HA, nuchal pain, syncope, dizziness, chest pain, palpitations

-SN to instruct Pt/Cg on Hypertension including s/s of exacerbation, complications necessitating medical attention, associated care & tx, & when to notify MD

-SN to assess BG level at each SN visit: Using aseptic technique & universal precautions SN to administer ______ (Enter insulin Dosage per Medication Record)

-SN to instruct Pt/Cg on Osteoarthritis including s/s of exacerbation, complications necessitating medical attention, associated care & TX, & when to notify MD

-SN to assess musculoskeletal status; report to MD s/s of osteoarthritis exacerbation; decreased mobility, activity intolerance, decreased endurance, increasing weakness, problems with ambulation & transfer, increased pain/numbness in extremity, edema, redness, crepitus; Assess the ineffectiveness of pain medication used to treat osteoarthritis

-SN to instruct Pt/Cg on measures to improve/promote mobility, & strengthening coping ability related to pain

-SN to instruct Pt/Cg on joint protection and safety

-SN to instruct Pt/Cg on Paralysis including s/s of exacerbation, complications necessitating medical attention, associated care & TX, & when to notify MD

-SN to assess & report to MD any abnormal changes neurological status, neurological deficits, mobility & activity intolerance, numbness or loss of sensation, paralysis on one side of the body


  • *POC GOALS ALL PATIENTS
  • Abscess
  • Alzheimer's Disease
  • Asthma
  • AV Graft
  • B12 injection
  • Bipolar
  • Blood Glucose Testing
  • Cancer of Lung/Bronchus
  • Cerebral palsy
  • Chronic Obstructive Asthma
  • Chronic Obstructive Bronchitis
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Congestive Heart Failure (CHF)
  • Constipation
  • Coumadin (Warfarin) use w/ pt/inr
  • Cirrhosis of Liver
  • Congestive Heart Failure (CHF)
  • Coronary Artery Disease (CAD)
  • Cystostomy
  • Depression
  • Diabetes (Primary)
  • Diabetes no accuchecks
  • Diabetic Ulcer
  • Dementia
  • Edema
  • Foley
  • Gastroesophageal reflux disease (GERD)
  • Hypertension
  • Hypertensive Chronic Kidney Disease
  • Idiopathic scoliosis
  • Lumbosacral Spondylosis
  • Myocardial Infarction (MI)
  • Nebulizer/inhaler
  • Osteoarthritis (w/ therapy)
  • Osteoarthritis (w/o therapy)
  • Ostomy
  • Oxygen Safety
  • Oxygen Saturation
  • Parkinson Disease
  • Percutaneous Endoscopic Gastrostomy (PEG)
  • PleurX catheter
  • Pneumonia
  • Pressure Ulcer Process Measure (no existing wounds)
  • Pressure Ulcer Process Measure: (with existing wounds)
  • Psoriasis
  • PT/INR ratio home testing
  • Rheumatoid Arthritis
  • Schizophrenia
  • Skin General
  • Suctioning
  • Surgical Wound
  • Tracheostomy
  • Urinary Tract Infection (UTI) (Secondary) w/ active infection
  • Urinary Tract Infection (UTI) w/o active infection
  • Venous stasis ulcer goal
  • Wounds all


Select a Goal from the dropdown to see example "goal" template text!

-Pt will achieve stable CV & Respiratory status as evidenced by VS W/in parameters in 9 wks

-Pt will remain in the home setting & not require unplanned medical care, emergent care or hospitalization for complications of disease exacerbation in 9 wks

-Pt/Cg will have increased understanding of interventions to mitigate pain as evidenced by pain less than 3/10 in 9 wks

-Pt/Cg will verbalize understanding of SN instructions related to fall precautions & safety measures to decrease risk of falls & prevent injury in 9 wks

-Pt/Cg will achieve increased knowledge of all medications & patient will achieve compliance w/ medication regimen in 9 wks

-Pt/Cg will be independent with blood glucose testing w/in 9 wks

-Pt will remain compliant w/ medication regimen, diet therapy, & other associated care/treatment as evidenced by absence of exacerbation or s/s of Congestive Heart Failure (CHF) necessitation the need for emergent, unplanned medical care, or hospital admission in 9 wks

-Pt will demonstrate understanding of interventions to reduce s/s of depression as evidenced by improved management of symptoms of depression in 9 wks

-Pt will achieve stable neurological status with no episodes of increased disorientation as evidenced by ability to carry out adl's at level normal for patient & no further loss of retained skills.

-Cg will verbalize understanding of ways to promote safe environment for patient in 9 weeks.

-Pt will verbalize understanding of edema relief measures & prevention in 9 wks

-Pt will have no exacerbation of Osteoarthritis including: decreased mobility, activity intolerance, decreased endurance, increasing weakness, problems w/ ambulation & transfer, increased pain/numbness in extremity, edema, redness, crepitus over the next 9 wks

-Pt/Cg will demonstrate proper ROM exercise and body alignment techniques


  • AUTOIMMUNE: LUPUS
  • AUTOIMMUNE: SJORGREN’S SYNDROME
  • CANCER: BREAST
  • CANCER: CHEMOTHERAPY
  • CANCER: LEUKEMIA
  • CANCER: LUNG
  • CANCER: MASTECTOMY
  • CANCER: OVARIAN
  • CANCER: PROSTATE
  • CANCER: RADIATION THERAPY
  • CV: A-FIB TEACHING INSTRUCTIONS--NOTIFY
  • CV: AMBULATORY CARDIAC MONITOR
  • CV: ANGINA PECTORIS
  • CV: ANEURYSM S/S TEACHING INSTRUCTIONS--NOTIFY MD
  • CV: ANGINA TEACHING INSTRUCTIONS--NOTIFY MD
  • CV: ANGINA TEACHING INSTRUCTIONS--S/S
  • CV: ARRYTHMIA/DYSRHYTHMIA
  • CV: ATHEROSCLEROSIS TEACHING INSTRUCTIONS--NOTIFY MD
  • CV: ATHEROSCLEROSIS TEACHING
  • CV: CAD
  • CV: CAD INSTRUCTIONS--NOTIFY MD
  • CV: CARDIOMYOPATHY INSTRUCTIONS-- S/S
  • CV: CARDIOMYOPATHY
  • CV: CHF
  • CV: CHF TEACHING INSTRUCTIONS –NOTIFY MD
  • CV: HDL
  • CV: HTN
  • CV: HTN INSTRUCTIONS--NOTIFY MD
  • CV: HTN INSTRUCTIONS LIFESTYLE
  • CV: HYPERLIPIDEMIA
  • CV: HYPOTENSION
  • CV: HYPOTENSION INSTRUCTION--NOTIFY
  • CV: MI
  • CV: MI INSTRUCTIONS--NOTIFY MD
  • CV: PACEMAKER
  • CV: PVD
  • CV: THROMBOPHLEBITIS
  • CV: VARICOSE VEINS
  • ELECTROLYTES: HIGH POTASSIUM (Hyperkalemia)
  • ENDOCRINE: CUSHING’S DISEASE
  • ENDOCRINE: DM FOOT CARE
  • ENDOCRINE: DM
  • ENDOCRINE: HYPERTHYROIDISM
  • ENDOCRINE: HYPOTHYROIDISM
  • GI: BOWEL RETRAINING
  • GI: BOWEL OBSTRUCTION
  • GI: CELIAC DISEASE
  • GI: CIRRHOSIS OF LIVER
  • GI: COLOSTOMY
  • GI: DIVERTICULAR DISEASE
  • GI: GALLBLADDER DISEASE
  • GI: GASTROSTOMY TUBES
  • GI: GERD
  • GI: HEMORRHOIDS
  • GI: HIATAL HERNIA
  • GI: ILEOSTOMY CARE
  • GI: NASOGASTRIC TUBE FEEDINGS
  • GI: PEPTIC ULCERS
  • GI: ULCERATIVE COLITIS AND CROHN’S DISEASE
  • GU: ACUTE RENAL FAILURE
  • GU: BLADDER RETRAINING
  • GU: BLADDER/URINARY CONTROL PROBLEMS
  • GU: CHRONIC RENAL FAILURE
  • GU: FOLEY CATHETER
  • GU: HEMODIALYSIS
  • GU: HEPATITIS
  • GU: PANCREATITIS
  • GU: PERITONEAL DIALYSIS
  • GU: PYELONEPHRITIS
  • GU: SUPRABUPIC CATHETER
  • GU: URINARY CALCULI
  • GU: UTI
  • HEALTH/SAFETY: AEROBIC EXERCISE
  • HEALTH/SAFETY: ALCOHOL AND ALCOHOL ABUSE
  • HEALTH/SAFETY: CANCER SCREENING/PREVENTION (BREAST)
  • HEALTH/SAFETY: CANCER SCREENING/PREVENTION (COLORECTAL)
  • HEALTH/SAFETY: CANCER SCREENING/PREVENTION (SKIN)
  • HEALTH/SAFETY: CANCER SCREENING/PREVENTION (ORAL)
  • HEALTH/SAFETY: CANCER SCREENING/PREVENTION (CERVICAL)
  • HEALTH/SAFETY: CANCER SCREENING/PREVENTION (PROSTATE)
  • HEALTH/SAFETY: CANCER SCREENING/PREVENTION (TESTICULAR)
  • HEALTH/SAFETY: CANCER SCREENING/PREVENTION
  • HEALTH/SAFETY: FALL PRECAUTIONS
  • HEALTH/SAFETY: FIRE SAFETY
  • HEALTH/SAFETY: FOOD SAFETY
  • HEALTH/SAFETY: HANDWASHING
  • HEALTH/SAFETY: IMMUNIZATIONS
  • HEALTH/SAFETY: ORAL HYGIENE
  • HEALTH/SAFETY: SKIN CANCER
  • HEALTH/SAFETY: STRESS
  • HEALTH/SAFETY: TOBACCO USE
  • HEALTH/SAFETY: FALL PREVENTION FOR ELDERLY
  • HEALTH/SAFETY: LATEX ALLERGY
  • HEMATOLOGY: DISSEMINATED INTRAVASCULAR COAGULATION
  • HEMATOLOGY: FOLIC ACID DIFICIENCY
  • HEMATOLOGY: HYPERBILIRUBINEMIA
  • HEMATOLOGY: IRON-DEFICIENCY ANEMIA
  • HEMATOLOGY: PERNICIOUS ANEMIA
  • HEMATOLOGY: POLYCYTHEMIA VERA
  • HEMATOLOGY: SICKLE CELL ANEMIA
  • HEMATOLOGY: THROMBOCYTOPENIA
  • INFECTION: MRSA
  • INFECTION: OSTEOMYELITIS
  • INFECTION: SHINGLES
  • INTEGUMENTARY: BURNS
  • INTEGUMENTARY: CELLULITIS
  • INTEGUMENTARY: DERMATITIS
  • INTEGUMENTARY: PSORIASIS
  • INTEGUMENTARY: VENOUS STASIS ULCERS
  • IV: IMPLANTED PORT ACCESS DEVICES
  • IV: PICC LINE
  • IV: TUNNELED CENTRAL VENOUS CATHETER
  • MEDICATION: ADMINISTRATION (EAR)
  • MEDICATION: ADMINISTRATION (NOSE)
  • MEDICATION: ADMINISTRATION (TRANSDERMAL)
  • MEDICATION: ADMINISTRATION (VAGINAL)
  • MEDICATION: ADMINISTRATION (RECTAL)
  • MEDICATION: ADMINISTRATION (METERED-DOSE INHALERS)
  • MEDICATION: ADMINISTRATION(METERED DOSE INHALERS W/ SPACER)
  • MEDICATION: ADMINISTRATION (ORAL)
  • MEDICATION: ADMINISTRATION (TABLET)
  • MEDICATION: ADMINISTRATION (LIQUID)
  • MEDICATION: ANTICOAGULANTS/ANTIPLATELETS
  • MEDICATION: ANTIDEPRESSANTS
  • MEDICATION: ANTI-PARKINSON
  • MEDICATION: ANTIULCER MEDICATION
  • MEDICATION: HIGH RISK
  • MEDICATION: ALL MEDICATIONS
  • MEDICATION: INSULIN
  • MEDICATION: LIPID-LOWERING DRUGS/HYPOLIPIDEMIC AGENTS
  • MEDICATION: NON-OPOID ANALGESIC
  • MEDICATION: ORAL ANTI-DIABETIC
  • MEDICATION: SAFETY
  • MEDICATIONS: ANTICONVULSANTS
  • MEDICATIONS: CARDIAC/CIRCULATORY
  • MEDICATION: COUMADIN USE INSTRUCTIONS
  • MEDICATIONS: DIURETICS
  • MS: AMBULATING W/ CRUTCHES
  • MS: AMPUTATION
  • MS: ANGIONEUROTIC EDEMA
  • MS: ARTHRITIS
  • MS: BODY MECHANICS
  • MS: CAUDA EQUINAE
  • MS: CAST CARE
  • MS: DEGENERATIVE CERVICAL DISC DISEASE
  • MS: DVT
  • MS: FRACTURES
  • MS: GOUT
  • MS: GOUTY ARTHRITIS
  • MS: HIP REPLACEMENT SURGERY
  • MS: HX OF FALLS
  • MS: JOINT PROTECTION
  • MS: LUMBAR INTERVERTEBRAL DISC DISEASE
  • MS: MUSCULAR DYSTROPHY
  • MS: OSTEOARTHRITIS
  • MS: OSTEOPOROSIS
  • MS: ORIF
  • MS: PAIN
  • MS: RA
  • MS: RELAXATION TECHNIQUES
  • MS: SCOLIOSIS
  • MS: USE OF CANE
  • NEURO: ALS
  • NEURO: ALZHEIMER’S DISEASE
  • NEURO: ANEURYSM
  • NEURO: CVA/STROKE
  • NEURO: DEMENTIA/DELIRIUM
  • NEURO: GUILLAIN-BARRE SYNDROME
  • NEURO: HEAD INJURY
  • NEURO: MULTIPLE SCLEROSIS
  • NEURO: PARKINSONS
  • NEURO: REALITY ORIENTATION
  • NEURO: SEIZURES/EPILEPSY
  • NEURO: SPINAL CHORD INJURY
  • NEURO: TIA
  • NUTRITION: BASIC NUTRIENTS/VITAMINS/MINERALS
  • NUTRITION: BASIC NUTRITION
  • NUTRITION: CLEAR LIQUID DIET
  • NUTRITION: DIABETIC DIET
  • NUTRITION: DYSPHAGIA
  • NUTRITION: FULL LIQUID BLENDERIZED DIET
  • NUTRITION: FULL LIQUID DIET
  • NUTRITION: HIGH CALORIE DIET
  • NUTRITION: HIGH FIBER DIET
  • NUTRITION: HIGH POTASSIUM DIET
  • NUTRITION: HIGH-PROTEIN DIET
  • NUTRITION: LACTOSE INTOLERANCE
  • NUTRITION: LOW-CALORIE DIET
  • NUTRITION: LOW FAT DIET
  • NUTRITION: LOW RESIDUE DIET
  • NUTRITION: LOW SODIUM DIET
  • NUTRITION: MECHANICAL SOFT DIET
  • NUTRITION: PUREED DIET
  • NUTRITION: TPN
  • NUTRITION: VEGETARIAN DIET
  • PSYCH: ANXIETY
  • PSYCH: BIPOLAR DISORDER
  • PSYCH: DEPRESSION
  • PSYCH: SCHIZOPHRENIA
  • PSYCH: SUICIDE
  • RESPIRATORY: ASTHMA
  • RESPIRATORY: COPD/ASTHMA
  • RESPIRATORY: COPD/ BRONCHITIS
  • RESPIRATORY: COPD/EMPHYSEMA
  • RESPIRATORY: COPD
  • RESPIRATORY: CYSTIC FIBROSIS
  • RESPIRATORY: EFFECTIVE BREATHING
  • RESPIRATORY: EFFECTIVE COUGHING
  • RESPIRATORY: ENERGY CONSERVATION
  • RESPIRATORY: ORAL/NASAL SUCTIONING
  • RESPIRATORY: OXYGEN THERAPY
  • RESPIRATORY: PNEUMONIA
  • RESPIRATORY: PNEUMOTHORAX
  • RESPIRATORY: PULMONARY EDEMA
  • RESPIRATORY: PULMONARY EMBOLISM
  • RESPIRATORY: TRACHEOSTOMY CARE
  • RESPIRATORY: TUBERCULOSIS
  • SENSORY: BLEPHARITIS
  • SENSORY: CATARACT REMOVAL
  • SENSORY: CATARACTS
  • SENSORY: CONJUNCTIVITIS
  • SENSORY: GLAUCOMA
  • SENSORY: HEARING LOSS
  • SENSORY: LABYRINTHITIS
  • SENSORY: MACULAR DEGENERATION
  • SENSORY: OTITIS MEDIA
  • SENSORY: RETINAL DETACHMENT


Select a Teaching from the dropdown to see example "teaching" template text!

SN instructed PT/ (CG) on systemic lupus erythematosus (SLP).

A. with SLP the body’s immune system does not function as it should. It produces antibodies that fight against the body’s healthy cells and tissue.

B. It is a chronic disorder with exacerbations and remissions.

C. It is an inflammatory disorder that causes structural changes in connective tissue affecting the skin, joints, muscles, and other organs.

D. Symptoms may range from mild to severe.

E. Symptoms may vary during the course of the disease.

PT/ (CG) verbalized understanding of ____.

SN instructed PT/ (CG) on breast cancer.

A. Breast cancer is second only to lung cancer as cause of cancer deaths in American women. One in every nine women may get breast cancer.

B. It is staged according to size of primary lesion, extent of spread to regional lymph nodes, and metastasis to other parts of body.

C. Paget’s disease is found in 1% to 4% of breast cancer. It involves skin changes in the nipple caused by a tumor growing through the ducts into the nipple.

PT/ (CG) verbalized understanding of ____.

SN instructed PT/ (CG) on ways to prevent one of the most common side effect of chemotherapy which is an infection caused by a low white blood count.

A. Wash your hands often such as before you eat, after you use bathroom, or after touching animals.

B. Obtain prompt treatment for any signs of infection.

C. Avoid people with upper-respiratory infections, flu, or chicken pox.

D. Avoid crowds.

E. Stay away from children who recently received “live virus” vaccines.

F. Maintain good nutrition and fluid intake.

G. Avoid cuts and scrapes. Clean and treat cuts/scrapes promptly.

H. Cook and prepare food carefully to prevent bacteria.

I. Take a warm (not hot) bath or shower and pat dry. Use lotions to soften the skin.

J. Do not eat raw fish, seafood, meat, or eggs.

K. Avoid contact with animal litter boxes, bird cages, and fish tanks.

PT/ (CG) verbalized understanding of ____.

SN instructed PT/ (CG) on cardiac arrhythmia or dysrhythmia.

A. The heart has its own conduction system that produces the rate and rhythm of each heartbeat.

B. When this conduction system is not working properly, the result is an abnormally slow or rapid heart rate that does not function in the usual manner.

C. Some arrhythmias do not need treatment, whereas other can quickly lead to life threatening situations.

PT/ (CG) verbalized understanding of ____.

SN instructed PT/ (CG) on congestive heart failure and its causes:

A. The heart is unable to pump sufficient blood to meet the body’s metabolic needs.

B. Heart failure describes the accumulation of blood and fluids in organs and tissues as a result impaired heart function.

C. Heart failure is classified as acute or chronic and right sided or left sided.

D. The primary reason for heart failure or decreased cardiac output is damage to muscular wall of the heart.

PT/ (CG) verbalized understanding of ____.


A second example...

SN instructed PT/ (CG) on the complications of CHF if untreated or managed poorly.

A. Acute pulmonary edema

B. Damage to organs such as liver, kidney, or brain

C. Pneumonia

D. Electrolyte imbalance related to diuretic therapy

E. Need for oxygen therapy

PT/ (CG) verbalized understanding of ____.

SN instructed PT/ (CG) on hypertension.

A. It is the occasional or continued elevation of diastolic or systolic pressure.

B. The systolic reading (the top number) represents the pressure exerted on the blood vessel wall when the heart is contracting.

C. The diastolic reading (the bottom number) represents the pressure on the blood vessel while the heart is at rest.

D. Although it is frequently asymptomatic and is considered the “silent killer.”

PT/ (CG) verbalized understanding of ____.


A second example...

SN instructed PT/ (CG) on Signs and symptoms of high blood pressure.

A. Dizziness

B. Headaches, often described as throbbing or pounding

C. Palpitations

PT/ (CG) verbalized understanding of ____.

SN instructed PT/ (CG) on the Foley catheter and its uses.

A. It is a catheter inserted through the urethra into the bladder to drain the urine.

B. It is usually inserted because of Incontinence (inability to hold urine), a neurogenic bladder, prostate surgery or obstruction causing an inability to release urine

C. An indwelling Foley catheter is held in place (in the bladder) by a small balloon filled with water.

PT/ (CG) verbalized understanding of ____.


A second example...

SN instructed PT/ (CG) on possible complications that can occur while using urinary catheter.

A. Urinary-tract infection: cloudy urine, foul odor, fever, and pain in bladder area.

B. Blocked catheter: lack of urine draining into catheter and firm, distended abdomen.

PT/ (CG) verbalized understanding of ____.


*Most teaching templates are divided among several subsets so the patient is not overloaded with too much information at once. The examples above are just one or two subsets.