Transcription of (485-14) SUPPLIES: Abdominal Pad 4 X 4 Gauze …
1 INITIAL ASSESSMENT. PATIENT NAME: (Last, First, Middle Initial) _____ PLAN OF CARE WORKSHEET. Page 3 of 4. (485-14) SUPPLIES: Abdominal Pad 4 X 4 Gauze Staple Removal Kit Ace Wraps Hydrogel Sterile Gloves Adaptik H202 Steri-Strips Alcohol Irrigation Set Suture Removal Kit Bard Film Barrier Wraps IV Supplies Syringes/Needles Betadine/Providone Kerlix Roll Gauze Tape Calcium Alginate Lancet Transparent Film Catheter/Tray/Bag Leg Bag Venipuncture Supplies Central Line Kits Non-Sterile Gloves Water (Sterile). Chemstrip Nu- Gauze Packing Strips Other_____. Feeding Tube/Supplies Ostomy Supplies _____. Foam Dressing Saline (Sterile). (485 21) INITIAL ASSESSMENT SUMMARY CLINICAL FINDINGS: Patient progressing toward pathway goals. Provide a brief summary of pertinent physical findings and /or knowledge deficits. T _____ P _____ R _____ BP _____ Blood Sugar: _____. _____. _____. _____. _____. _____. _____. _____. Physician will be notified of patient discharge Discharge summary is available upon request (485-22) Goals: RN: (Stabilization of disease with increased knowledge and independence in care and management of disease).
2 Other Individualized goal: _____. PT/OT/SLP (Understanding of home program) Other: _____. RD (Increase knowledge of special diet) Other: _____. MSW (Appropriate use of resources) Other: _____. HHA (Promote good hygiene, prevent skin breakdown and improve ability to manage personal care). (485-22) Discharge Plans: 1. Discharge when disease process has stabilized and goals met. 6. Plan to discharge in _____ weeks to care of self/caregiver 2. Discharge when patient/caregiver can manage health care 7. D/C when pt/caregiver understand home program and goals met 3. Continue service for catheter care 8. Other individualized discharge plan(s). _____. 4. Continue service for feeding tube changes _____. 5. Continue service for B12 injections _____. Form # 67-55 Rev. 2/10 PAGE 3-C.
