Navy-Marine Corps Relief Society Visiting Nurse Monthly Report

Office:

Month of:

New Cases for the Month:

Patient Initiated

Military Referral

Civilian Referral

Other    Source

Maternal/Infant

/

/

/

/

Med/Surg

CCA Contacts

Other

Total New Cases for the Month:

0

Patient Contacts:

Initial Home Visits

Additional Patient Contacts

Maternal/Infant:

/

Hospital Visits:

Medical:

Class Participants:

Pediatric:

(primary speaker only)

Surgical:

Clinic/Office Visits:

Other:

Telephone Assessments:

CCA/CRA:

Follow-up Home Visits:

Attempted Visits:

CCA/CRA Follow up

Mail-Out Meds/Information:

Total Patient Contacts:

0

Additional Duties

Pharmacy Visits:

Admin Duties:

Conferences:

Miles Driven:

Referrals to Others:

Volunteers Used:

Phone Calls (approx.):

Vol. R.N. Hours:

Clinics/Classes Held:

Continuing Ed. Hours:

Primary Speaker:

CEUs Received:

Contributor:

Other:

Comment:

Submitted By: