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NTERDISCIPLINARY PLAN OF CARE AND PATIENT EDUCATION RECORD pg 4 of 5
Transporter Training Handout
Adm Dx:
NONRE-BREATHER O2 MASK VENT PT ON MONITOR MONITOR
65yo Fe CT Abd ICU or Renal scan Cardiac Cath or Stress Test
Nurse
IVF
How will this ON
one be transported? 15
Change toO2 4l NC Can You take pt yourself? Why
pt refuses O2
How will this one be transported? Change senario to Telemetry
Can You take pt yourself? Why7
How will this one be transported? & IVF??
FALL/ELOPEMENT/RESTRAINTS Handoff Communication Detail Focus: Other Date Sched
PCU pt Support Needs Situation/Procedure:
young male going for STAT CT Head
green arm band on ??? & also Personal Needs
he yells
out _____________________
Safety Needs
IR PT___ INR____ PTT____ date_____
How will this one be transported? Physical Needs: Transport Via
Does he need anything else before? ______________
Handoff Communication Detail
DEAF DOES NOT KNOW ABOUT TEST/OR Transport process using SBAR 3 MONTH OLD CXR/F&U ABD
(circle as appropriate) Handoff communication requires signature
1) when picking up patients go to chart first, it
ALWAYS should go with patient
2) IN CHART TO MULTIDISCIPLINARY
3) transport per these instructions, if blank or
seems innacurate ask nurse/chg nurse
How will this one be transported? and for what you are taking them How will this one be transported?
Teaching Method Response Date/Initial Teaching Method Response pt returns LEGENDontrast dye 1 2 3 4 P/F 1 2 3 4 P/F complete upon admissicomplete at dis
MRI 1 2 3 4 P/F 1 2 3 4 P/F Method:
CT scan 1 2 3 4 P/F 1 2 3 4 P/F
NPO 1 2 3 4 P/F 1 2 3 4 P/F Response:
Colon Prep 1 2 3 4 P/F 1 2 3 4 P/F
tress Trest 1 2 3 4 P/F 1 2 3 4 P/F
Hold Metformi 1 2 3 4 P/F 1 2 3 4 P/F
Date Signature/Discipline Initals Date Signature/Discipline Initals
Allergic to contrast dye: ___Yes ___No Use for:procedure off unit/req.prep/traumatic/Inho
TRANSPORT
ituation/Procedure: Situation/Procedure:NRB 100% NURSE MONITOR VENT wheelchair
stretcher stretcher
O2 4LPM NC
stretcher
ituation/Procedure: with contr
wheelchair Telemetry Transport Monitor O2 @________ IR guided biopsy needle aspirat
Nurse Vent _____________________
Nuc MedHIDA scan
Deaf Blind HOH Background (Dx/Hx/symptoms r/t situLanguage Barrier_______________________ pain____
HIDA scan no pain meds/ 8hrs p
Fall Precautions Restraints Assessment: If with contrast Bun___
Confused Elopement (may wander)
(init)___correct pt ___correct prep ___co
Wheelchair parent lap Recommendation critical value__
stretcher/bed Pt tol exam: well refused poor needs
complete return @_____ini/date
Situation/Procedure: Situation/Procedure:
Deaf wheelchair
TAB, OPEN TO THIS PAGE OF POC (PLAN OF Care)
to fill it in DO NOT TAKE PT TIL FILLED IN
4) Nurse or Chrg Nurse must sign correct pt/prep/test
before pt can go you MUST know to where
5) tech/nurse in dept must check complete or retrun BEORE
1= Verbal/1:12=Demonstrat
3=Written Material4= Audio/Vis
=Patient F=Fam
A=Asked questionsReturn Demonstrates
B=Poor AttentionN=Needs Reinforceme
D=Verbalizes UnderstandingC=Denial/Res
Teaching Goals: P or F is able
ImImSickSickSamSam
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patient label
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rge
Transfer
n)
_
t test
_
_
D or E
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INTERDISCIPLINARY PLAN OF CARE &
update Q 24 hours PATIENT/FAMILY EDUCATION RECORD update Q 24 hourSection I) PATIENT EDUCATIONAL NEEDS ASSESSMENT (circle appropriate responses
Readiness to learn: Support System: Preferred Method:
K 1 2 3 4 5 6 7 8 9 10 11 12 Technical/Vocational spouse family Verbal (1:1) Written Video
College 1 2 3 4 Master's_______ Doctorial friend none Demonstration No Pref.
(circle all that apply)
Section II) BASIC PATIENT SAFETY NEEDS Priority H=High, M=Medium, L=Low
Initiated by _____________ Date_____ H M L Initiated by _________ Date________ H M L Initiated by _________ Date___ H M L
Priority change Date_______ Initials_ H M L Priority change Date_______ Initials_ H M L Priority change Date_______ In H M L
Interventions: Interventions: Interventions:
P&P CP3012
-Score =/>15 & pediatrics(13 & und
Teaching Method Response Date/Initial Teaching Method Response Date/Initial -green armband -observe Q1
Pt Ed Hndbk P/F Scale 0-10 P/F -bed alarm activated -up with ass
Orient to Rm P/F Managemen 1 2 3 4 P/F -BRP Q4hr, & Q2hr if incontinent/dia
Call light P/F Rx: 1 2 3 4 P/F -half side rails up -pt/family tea
MCM Guide P/F Rx: 1 2 3 4 P/F -care with pain meds & sedatives
Desired Outcome (Goals) Goal Met Desired Outcome (Goals) Goal Met
Y N Y N
Y N Y N
__Verbalize Pre/Intra/Post Surgical Pl Y N __ Pain relief with medication Y N
Plan if not Met: ________________________________Plan if not Met: ______________________________Teaching Method Response Date/Initial
Resolved by ________________ Date _________ Resolved by ________________ Date _________Name/DOB P/F
Fall Risk P/F
Initiated by _______________ Date___ H M L Initiated by _________ Date________ H M L Med Recon P/F
Priority change Date_______ Initials_ H M L Priority change Date_______ Initials_ H M L Stop Smoke P/F
Interventions: 1 2 3 4 P/F
1 2 3 4 P/F
specific/culturaly acceptable interventions Desired outcomes (Goals) Goal Met
Y N
Y N
Y N
Plan if not Met: ________________________
Teaching Method Response Date/Initial Teaching Method Response Date/Initial Resolved by _____________ Date _______
Wash Hands P/F Interpreter 1 2 3 4 P/F LEGENDIsolation 1 2 3 4 P/F Com Board 1 2 3 4 P/F complete upon admiscomplete at disch
S/S Infection 1 2 3 4 P/F 1 2 3 4 P/F Method:
Desired outcome (Goal) Goal Met Desired outcome (Goals) Goal Met
__No S/S of infection Y N Y N Response:
__TPR within normal limits for patien Y N __Verbalizes understanding of all te Y N
__No redness/drainage wound/inserti Y N _ ______________________ Y N
Plan if not Met: ________________________________Plan if not Met: ______________________________
Resolved by ________________ Date _________ Resolved by ________________ Date _________
Date Signature/Discipline Initals Date Signature/Discipline Initals
patient label
Educational Level:(circle highest grade completed)
Interested
UninterestedBarriers Speech/Language________________ Visual Hearing Cultural/Religious Cognitive Emotional
Educational Level Literacy Financial Pain Physical Medical Equipment Denial
1. FOCUS: KNOWLEDGE DEFICIT 2. FOCUS: COMFORT/PAIN 3. FOCUS: SAFETY
Provide for priva
Provide patient education handbook Assess and meet personal need Identify patient by name & DOB P&PA
Provide MCM patient visitor guide Assess pain every shift and PRN Visual assessment as per policy
Orient to room and hospital environment Utilize appropriate pain scale Maintain JCAHO Safety Goals
Instruct on call light use Use alternative therapies for pain relief Fall risk appraisal (ADM, Daily, Condi
Instruct on phone use & room telephone n Assess pain medication effectiveness -Score
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pg 1 o
INTERDISCIPLINARY PLAN OF CARE AND PATIENT EDUCATION RECORD pg 2 of 5Section III) PATIENT PHYSIOLOGICAL & SUPPORT NEEDS Priority H=High, M=Medium, L=L
6. FOCUS SKIN INTEGRITY 7. FOCUS: RESPIRATORY 8. FOCUS: CARDIAC FUNCTION
Initiated by _______________ Date___ H M L Initiated by _______________ Date__ H M L Initiated by _______________ D H M
Priority change Date_______ Initials_ H M L Priority change Date_______ Initials_ H M L Priority change Date_______ In H M
Interventions: Interventions: Interventions:
& PRN, Routine: M/S tid, ICU Q1hr, P
ER/WC/Surg Sxs per patient conditio
Teaching Method Response Date/Initial Teaching Method Response Date/Initial Teaching Method ResponseDate/In
Drsng chngs 1 2 3 4 P/F O2/nebs 1 2 3 4 P/F S/Sangina 1 2 3 4 P/F
Waffle mattre 1 2 3 4 P/F S/S VAP 1 2 3 4 P/F Warning MI 1 2 3 4 P/F
1 2 3 4 P/F CDB, Insp Q1h 1 2 3 4 P/F Rx 1 2 3 4 P/F
1 2 3 4 P/F MDI 1 2 3 4 P/F Rx 1 2 3 4 P/F
Desired outcome (Goals) Goal Met Desired outcomes (Goals) Goal Met Desired outcomes (Goals) Goal M
__No or improved existing skin break Y N __Patent airway Y N __BP & P WNL for patient Y N
__No S/S of infection Y N __ABG/O2 Sats WNL Y N __Optimal C.O./function for pat Y N
__Surgical wound healing w/o compli Y N __Bilateral breath sounds clear Y N __Decrease in ectopy dysrhyth Y N
__Verbalize understanding/demonstr Y N __Improved cough, airway clearing Y N __Verbalizes understanding of Y N
Plan if not Met: ________________________________Plan if not Met: ______________________________ Plan if not Met: ______________________
Resolved by ________________ Date _________ Resolved by ________________ Date _________ Resolved by ________________ Date _
9. FOCUS: IMMOBILITY(Musc/Skeletal)
Initiated by _______________ Date___ H M L Initiated by _______________ Date__ H M L Initiated by _______________ D H M
Priority change Date_______ Initials_ H M L Priority change Date_______ Initials_ H M L Priority change Date_______ In H M
Interventions: Interventions: Medication review:
Interventions:
Teaching Method Response Date/Initial Teaching Method Response Date/Initial Teaching Method ResponseDate/In
Assist Device 1 2 3 4 P/F IV therapy 1 2 3 4 P/F I & O 1 2 3 4 P/F
1 2 3 4 P/F 1 2 3 4 P/F 1 2 3 4 P/F
Desired outcome (Goal) Goal Met Desired outcome (Goal) Goal Met Desired outcome (Goal) Goal M
__No complications related to immob Y N __Fluid Intake adequate/ouput WNL Y N __No adverse drug events Y N
__No decrease in ROM/Activity as tol Y N __VS &hemodynamics stable/labs W Y N __Verbalizes understanding of Y N
Plan if not Met: ________________________________Plan if not Met: ______________________________ Plan if not Met: ______________________
Resolved by ________________ Date _________ Resolved by ________________ Date _________ Resolved by ________________ Date _12. FOCUS: ELIMINATION/CONSTIPATION 13. FOCUS: GASTROINTESTINAL 14. FOCUS: NUTRITION
Initiated by _______________ Date___ H M L Initiated by _______________ Date__ H M L Initiated by _______________ D H M
Priority change Date_______ Initials_ H M L Priority change Date_______ Initials_ H M L Priority change Date_______ In H M
Interventions: Interventions:
Teaching Method Response Date/Initial Teaching Method Response Date/Initial Teaching Method ResponseDate/In
1 2 3 4 P/F 1 2 3 4 P/F lo Na/lo ch 1 2 3 4 P/F
1 2 3 4 P/F 1 2 3 4 P/F 1 2 3 4 P/F
Desired outcome (Goals) Goal Met Desired outcomes (Goals) Goal Met Desired outcome (Goals) Goal M
Dietician consult
Implement protocol for Braden
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__Verbalizes understanding bowel pr Y N __No c/o nausea, vomiting, diarrhea Y N __Weight maintain/loss/gain ne Y N
__Bowel sounds present/soft formed Y N __Hemodynamically stable/no s/s GI Y N __Nutritional/healing needs me Y N
Plan if not Met: ________________________________Plan if not Met: ______________________________ Plan if not Met: _______________________
Resolved by ________________ Date _________ Resolved by ________________ Date _________ Resolved by ________________ Date __
INTERDISCIPLINARY PLAN OF CARE AND PATIENT EDUCATION RECORD pg 3 of 5Section III) PATIENT PHYSIOLOGICAL & SUPPORT NEEDS Priority H=High, M=Medium, L=Lo
15.FOCUS: PERIPHERAL VASCULAR 17.FOCUS: ENDOCRINE 16.FOCUS: NEUROLOGICAL
Initiated by _______________ Date___ H M L Initiated by _______________ Date__ H M L Initiated by _______________ D H M L
Priority change Date_______ Initials_ H M L Priority change Date_______ Initials_ H M L Priority change Date_______ Ini H M L
Interventions: Interventions: Interventions:
`
lab values/vit neuro checks, critical values.
Teaching Method Response Date/Initial Teaching Method Response Date/Initial Teaching Method ResponseDate/Init
keep ext warm 1 2 3 4 P/F DM dx process 1 2 3 4 P/F Warning CVA 1 2 3 4 P/F
1 2 3 4 P/F Glucometer 1 2 3 4 P/F 1 2 3 4 P/F
1 2 3 4 P/F 1 2 3 4 P/F 1 2 3 4 P/F
Desired outcome (Goal) Goal Met Desired outcomes (Goals) Goal Met Desired outcomes (Goals) Goal M
__Skin W/D with capillary refill
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1 2 3 4 P/F 1 2 3 4 P/F
Date Signature/Discipline Initals Date Signature/Discipline Initals
patient label
INTERDISCIPLINARY PLAN OF CARE AND PATIENT EDUCATION RECORD pg 4 of 5
Adm Dx:
Focus: Radiology
Date Sched Focus: Radiology
Date Sched Focus: Nuc Med
Date Sch
__/__correct pt__/__correct prep__/__cor
Focus: Radiology Date Sched Handoff Communication Detail Focus: Other Date Sched
Support Needs Situation/Procedure:
Personal Needs
_____________________
Safety Needs
IR PT___ INR____ PTT____ date_____
Physical Needs: Transport Via
______________
Handoff Communication Detail
Focus In-House Transfer Focus In-House Transfer Focus In-House Transfer
(circle as appropriate) (circle as appropriate
RF DM GI Bleed CP CVA ________________ RF DM GI Bleed CP CVA _______________ RF DM GI Bleed CP CVA _________
TPR________ B/P_____ TPR________ B/P_____ TPR________ B/P_____
LBM______ IV site________ Fld________ rate____mlLBM______ IV site________ Fld________ rate____ LBM_____ IV site______ Fld_______ rate__
A&O X ____ incont fole Skin:_______ A&O X ____ incont fole Skin:_______ A&O X ____ incont folSkin:_______
Q&A Q&A Q&A
Orders Orders Orders
Date__________ Initials From_______ To______ Date__________ Initials From_______ To______ Date__________ Initials From_______ To_
Teaching Method Response Date/Initial Teaching Method Response Date/Initial LEGENDcontrast dye 1 2 3 4 P/F 1 2 3 4 P/F complete upon admiscomplete at disch
MRI 1 2 3 4 P/F 1 2 3 4 P/F Method:
CT scan 1 2 3 4 P/F 1 2 3 4 P/F
D=Verbalizes UnderstandingC=Denial/Resis
Teaching Goals: P or F is able
Section IV) SUPPORT & Handoff Communication (SBAR Methodology) S/B=nurse A=nurse/tech R=tech
Allergic to contrast dye: ___Yes ___No Use for:procedure off unit/req.prep/traumatic/Inh
Situation/Procedure: with contrast Situation/Procedure: with contrast Situation/Cardiac Stress TestCTMRI : head abd_______ ______________ CTMRI : head abd_______ ______________ Adenosine/thallium Dobutaine/thalliu
Sono(US): R/LLE abd_____ _____________ Sono(US): R/LLE abd_____ _____________ Persantine/thallium _____________
UGI LGI(BE) Hypaque _____________ UGI LGI(BE) Hypaque _____________ Exercise (not a nuc med scan
Background:(Hx r/t situation/presenting symp Background:(Hx r/t situation/presenting sym Background: Cardiac Hx/symptomspain____ LOC Trauma _____________ pain____ LOC Trauma _____________ CP MI Stents/CVI CABG______
claustrophobia/anxiety P re-Med w/__________claustrophobia/anxiety P re-Med w/_________Surgical Clearance _________________
x MRI:ICD prosthesis
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NPO 1 2 3 4 P/F 1 2 3 4 P/F Response:
Colon Prep 1 2 3 4 P/F 1 2 3 4 P/F
Stress Trest 1 2 3 4 P/F 1 2 3 4 P/F
Hold Metformi 1 2 3 4 P/F 1 2 3 4 P/F
Date Signature/Discipline Initals Date Signature/Discipline Initals
patient label
INTERDISCIPLINARY PLAN OF CARE AND PATIENT EDUCATION RECORD pg 5 of 5
Section V) PATIENT AGE SPECIFIC CARE NEEDS Initial Box Representing the Patient's Care Need
=Patient F=Famil
A=Asked questions= Return Demonstrates
B=Poor AttentionN=Needs Reinforcement
D=Verbalizes UnderstandingC=Denial/Resist
Teaching Goals: P or F is able t
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Date Signature/Discipline Initals Date Signature/Discipline Initals
patient label
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r) use:
t
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ge
2003
onr)
inuum
D or E
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2hr,
__
__
__
__
policy
ics)
c
policy
it vals
eight
s
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__
__
__
__
__
__
ge
stance
needs
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ct test
l/hr
___
ge
D or E
se Transfer
hr
__
__
on)
__
ct test
__
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ol)
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D or E
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A) The Basics
1) Read these instructions before attempting to complete this form to ensure2) Place a patient label in the spaces on the bottom right corner of the pages indicated.
3) There is a legend located on the bottom right corner of pages 1, 3, 4, and the addendum page for your
shading are required at admission, areas of light-gray shading are required at discharge on any
Select the Focuses for which the patient requires intervention and teaching this admission: Initia
and dating next to "initiated by:" select priority H=high, M=Medium, L=low, Select appropriate i
At discharge each focus are that has been initiated must be resolved, cirlde Y=Yes indicating go
is true. Circle N=No if it is false and next to "plan if not met" write what the follow-up plan is: "N
are responsible that the patient/caregiver receives the education necessary to manage their car
Interventions to relieve symptoms, Procedures (ambulatory devices, equipment, wound care etc
of Refusal of care, etc. Educational items that are required or are frequently used have been ad
then (see legend) circle method, patient and or family, add the letter(s) that describe the patien
the communication to ensure patient safety when the patient is off of the unit and out of the car
i) radiology exams off unit that requiring preps, these require safisticated communication betweii) in house transfers from any unit to any other unit: since care and charge nurses are changing
should document on the form as appropriate for that disciplines interventions, education etc. Ea
place your initials, signature and date at the bottom of the form in the indicated box. (on one p
B) Section I Patient Educational Needs Assessment Section (page 1) & Section V Age Specific
1) Complete at the time of admission with the Admission Assessment (M/S admit nurse, ICU/PCU/ER hold p
responses for each topic. Page 5 initial the box in the focus section appropriate for the patient, c
2) Readiness to learn: circle either "interested" or "uninterested" as appropriate, if there are any barriers t
circle all baariers the patinet/family has, next to Speech/Language indicate primary language, or
C) Section II Basic Patient Safety Needs
1) The areas with the patterned shading are required to be completed upon admission. On Focus 1 indicat2) Each of these focuses are basic care needs. Focuses 1-5 contain some interventions basic to all patient'
3) Teaching should be done as indicated by the pattern shaded areas upon admission by circling method,
letter(s) that describe the patient's/famiDocument any other teacing done.
5) Focus 3 Safety contains the fall risk interventions, if the score is =/>15 ALL interventions Must be initia
D) Section III Patient Physiological and Support Needs
1) Select the appropriate Focuses the correspond to the primary diagnosis, other diagnoses/care issues re
3) Pharmacy and Discharge Planning are responsible for their Focus areas.
E) Discharges (solid gray shaded areas)1) The primary care nurse assigned to the patient at discharge is required as part of discharge documenta
F) Update Daily:
1) Review each focus initiated and if any issues are resolved indicate by circling Goal Met "Y=Yes" (note f
2) Add new focus areas: use assessment, added medications, test results and new consults as suggetions
3) Change the priority level according to patient needs by initialing/dating/circling new priority level next t
G) Section IV Patient Support and Handoff Communication Needs
S=Situation, B=Background, and teahing of the proedure and any prep (hand out "radiology exa
A=Assessment will have lab value added as indicated, and at the time the patient is taken to ra
correct pt/prep/test, the radiology tech will initial the same when pt is in department before the
Instructions: INTERDISCIPLINARY CARE PLAN & PATIENT/FAMILY ED
4) The care plan is required to be initiated upon admission and updated and daily by various regulatory
5) This form combines three required sets of documentation:
a) an interdisciplinary plan of care: guides the care based on the focus(health and care issu
standards (standards of care are what a reasonable and prudent professional is accountable to d
b) an interdisciplinary patient/family education record: ALL education should be docume
c) a hand off communication tool/record: this is located on page 4 and on the addendum pa
iii) situations meeting the statement in "5c". (handoff communication during change of shift, pre
6) This form is interdisciplinary (all disciplines: Nursing/PT/SLP/RT/Dietician/Rx/Case Management/Social
goals have been preselected and represent MCM basic standards of care. Select other interventi
check the indicated box, and these patients are high risk for falling
teaching. Fill out each section as indicated in A5a above.2) Document all teaching done, add items as needed as indicated in A5b above there are extra teaching
with the acception of pharmacy and discharge planning. See A5b above.
1) Radiology/Nuc Med/Other: For the types of procedures described in A5c above the care/charge nurse
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filled out before the patient returns to floor as indicated, the tech will initial and date, and fill ou
2) In House Transfer all sections will be filled out by transfering nurse, when the patient arrives at new uni
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roper completion
convenience. Areas of patterned
ocus initiated.
te the appropriate focuses by initialing
nterventions/goals. /
als met if the Goal statement
to___" D/c to LTAC" etc.
e including: Diagnosis, Medications,
), Diet, Plan of Care, Consequences
ed for you, add others as needed
t's/family's response, date & initial
e of the primary/charge nurse. Such as:
en disciplines
ch time YOU document on the form
ge is all that is necessary)
are Needs (page 5)
rimary nurse) by circling appropriate
omplete signature box at bottom.
o learning please circle "barriers" and
things like aphasic.
e primary diagnosis.s care needs. These interventions and
patient and or family, add the
ed. If the patient requires restraints
quiring significant interventions and
tion to resolve each Focus area
cus 1-5 are NOT resolved until D/C.
for changes to the plan.
o "Priotity change"
ms"under procedures on Z-drive)
iology the care/charge nurse initials
procedure. R=Rcommendation will be
UCATION RECORD
agencies. Nursing is responsible.
s) and each disciplines intervention
o based on liscensure & training)
ted in the "teaching" sections. YOU
ge. This document encompasses
-post procedures are NOT done here)
Work etc.) involved in the case
ons and goals as needed. See A5a
slots at the bottom of page 3
ssigned to the patient will document
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signaure section at bottom of page.
t both nurses will initial as indicated.
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INTERDISCIPLINARY PLAN OF CARE
CASE CONFERENCE RECORDDATE:______________________ ANTICIPATED DISCHARGE DATE:________________________
NEED AREA TREATMENT PLAN VARIANCES DISCHARGE PLA
Discharge Outcome Return to:_______________ Unable to return
Needs
Support
Needs
Personal
Admit Needs
ATTENDING: Safety
CM SW NURSING Needs
REHAB CARDIOPULM
DIETICIAN RX Physical
PHYSICIAN Needs
Date Signature/Discipline Initals Date Signature/Discipline Initals
patient label
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INTERDISCIPLINARY PLAN OF CARE AND PATIENT EDUCATION RECORD ADDENDUM
Adm Dx:
Focus: Radiology Date Sched Focus: Radiology Date Sched Focus: Nuc Med Date Sch
__/__correct pt__/__correct prep__/__cor
Focus: Other Date Sched Focus: Other Date Sched Focus: Other Date Sched
Situation/Procedure:
Assessment: Assessment:
initial/date initial/date initial/date
Focus In-House Transfer Focus In-House Transfer Focus: Other
(circle as appropriate) (circle as appropriate)
RF DM GI Bleed CP CVA ________________RF DM GI Bleed CP CVA __________________
TPR________ B/P_____ TPR________ B/P_____
LBM______ IV site________ Fld________ rate____mLBM______ IV site________ Fld________ rate____ml/hr
A&O X ____ incont fole Skin:_______ A&O X ____ incont fole Skin:_______
Q&A Q&A Q&A
Orders Orders
Date__________ Initials From_______ To______ Date__________ Initials From_______ To______ initial/date
Teaching Method Response Date/InitialTeaching Method Response Date/Initial LEGEND ADDENDUcontrast dye 1 2 3 4 P/F 1 2 3 4 P/F complete upon admicomplete at discha
MRI 1 2 3 4 P/F 1 2 3 4 P/F Method:
CT scan 1 2 3 4 P/F 1 2 3 4 P/F
NPO 1 2 3 4 P/F 1 2 3 4 P/F Response:
Colon Prep 1 2 3 4 P/F 1 2 3 4 P/F
Stress Trest 1 2 3 4 P/F 1 2 3 4 P/F
Hold Metformi 1 2 3 4 P/F 1 2 3 4 P/F
Date Signature/Discipline Initals Date Signature/Discipline Initals
Section IV) SUPPORT & Handoff Communication (SBAR Methodology) S/B=nurse A=nurse/tech R=tech
Allergic to contrast dye: ___Yes ___No Use for:procedure off unit/req.prep/traumatic/In
Situation/Procedure: with contrast Situation/Procedure: with contrast Situation/Cardiac Stress TestCTMRI : head abd_______ ______________ CTMRI : head abd_______ ______________ Adenosine/thallium Dobutaine/thalliu
Sono(US): R/LLE abd_____ _____________ Sono(US): R/LLE abd_____ _____________ Persantine/thallium _____________
UGI LGI(BE) Hypaque _____________ UGI LGI(BE) Hypaque _____________ Exercise (not a nuc med scan
Background:(Hx r/t situation/presenting sympBackground:(Hx r/t situation/presenting sympBackground: Cardiac Hx/symptomspain____ LOC Trauma _____________ pain____ LOC Trauma _____________ CP MI Stents/CVI CABG______
claustrophobia/anxiety P re-Med w/_________ claustrophobia/anxiety P re-Med w/_________ Surgical Clearance _________________
x MRI:ICD prosthesis
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patient label
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ct test
e
use Transfe
hr
__
__
ion)
e)
D or E
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