I. ASSESSMENT Name Click here to enter text.DOB XXXXXXX
- 1. I. ASSESSMENT Name: Click here to enter text. DOB: XX/XX/XXXX Date of Admission: Click here to enter a date. Assessment Date: Click here to enter a date. Admitting Diagnosis: Click here to enter text. Past Medical History (include surgical history) Click here to enter text. Subjective history of current hospitalization (what led to current hospitalization?) Family and social history Click here to enter text. Summary of physical assessment (complete head-to-toe from hospitalization documentation) Click here to enter text. Allergies: Click here to enter text. Effects of diagnosis on daily living: Click here to enter text. Current Medications (to add rows, click “insert row” on Table Layout tools) Name Dose Schedule
- 2. Last taken Activity of Daily Living and Instrumental Activity of Daily Living Assessment (Place an “X” in the appropriate column) Activity Not applicable Dependent Semi Independent Bathing Dressing
- 4. Shopping Food Preparation Managing Medications Using the Phone Housework Laundry Transportation
- 5. Managing Finances Total Patient Support System (based upon above assessment, who is available to provide care or support to patient) Name Relationship AvailabilityClick here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text. Medical Follow-upClick here to enter text. Financial SummaryClick here to enter text. II. DIAGNOSIS/PLAN List your top three priorities, create a nursing diagnosis, and create two goals for each Priority 1. Click here to enter text. 2. Click here to enter text. 3. Click here to enter text.
- 6. Nursing diagnosisClick here to enter text.Click here to enter text.Click here to enter text. Client outcomes 1. Click here to enter text. 1. Click here to enter text. 1. Click here to enter text. 2. Click here to enter text. 2, Click here to enter text. 2. Click here to enter text. III. EDUCATION NEEDS Need Method Evaluation of learningClick here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text.Click here to enter text. I. Future Medical Care - Routine Routine Care Description Frequency of visits Purpose Cost per visit Cost per year
- 7. IV. FINANCIAL WORKSHEET Subtotal II. Future Medical Care - Specialty Description Frequency Purpose Cost per visit Cost per year Subtotal III. Future Medical Care – Treatment Interventions Recommendation Frequency of procedure Purpose Cost per procedure Cost per year
- 8. Subtotal IV. Medication Needs Name/dose Schedule Purpose Cost per month Cost per year Subtotal V. Supplies Supplies Schedule Purpose Cost per month Cost per year
- 9. Subtotal VI. Diagnostic Testing Diagnostic Test Schedule Purpose Cost per month Cost per year Subtotal VII. Future Adjunctive Therapies Therapy Purpose Frequency Cost per month
- 10. Cost per year Subtotal VIII. Medical Equipment Equipment Purpose Purchase/Rental Cost per month Cost per year Subtotal IX. Transportation Mode Purpose Purchase/PRN Cost per month
- 11. Cost per year Subtotal X. Home Furnishings and Adaptations Need Purpose Initial cost Upkeep Final cost Subtotal XI. Potential Complications Complication Estimated Cost
- 12. Subtotal Financial Summary Description Cost per Year Non-recurring cost I. Future Medical Care - Routine II. Future Medical Care - Specialty III. Treatment Interventions IV. Medication Needs V. Supplies VI. Diagnostic Testing VII. Future Adjunctive Therapies
- 13. VIII. Medical Equipment IX. Transportation X. Home Furnishings and Adaptations XI. Potential complications TOTAL: V. REFLECTION AND CONCLUSION