Nurse met
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ORIENTATION
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Add updates:
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eye contact
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gait
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Rate of speech
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hygeine
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clothing
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description of symptoms
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Nurse observed
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dx understanding
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Add updates:
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DENIES SI/HI
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*** POSITIVE SI/HI***
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affect
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******Mood "___" *******
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INJECTION Administered
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INJECTION SITE
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injection INTERVENTION
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Intervention BASIC
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NO MEDICATION INTERVENTION
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ALL Intervention (select)
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Intervention MUST INPUT
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Intervention COMM RESOURCES
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Intervention PHARMACY
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Intervention SOCIAL/ BOUNDARIES
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Intervention COPING
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Intervention FLUID & RESTRICTION
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Intervention FALL PREVENTION
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Intervention CAFFEINE
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Intervention HEALTHY WEIGHT
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Intervention MEDICAID TRANSPORT
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MEDICATIONS
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Intervention SAFETY PLAN
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Intervention DIABETES
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Intervention HYGIENE
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Intervention HTN
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Intervention BMI
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Intervention OBESITY
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Intervention HEALTHY EATING
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EMPHYSEMA
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Intervention LAB-WORK
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Intervention ASTHMA
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Intervention COPD
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ROI
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Intervention HF
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Intervention DIALYSIS
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Intervention NA & AIMS
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Intervention SEIZURES
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Intervention SCHEDULED MD APPT
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Intervention PAIN
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Intervention EMPATHETIC RESPONSE
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Intervention SOBRIETY & TOBACCO
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WT
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VITAL SIGNS
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HT
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2nd BP READING (high)
/
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HIGH BLOOD PRESSURE
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Blood sugar
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select a current medication
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Diabetes RESPONSE
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Add info:
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MEDICATION compliance
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NO MED SIDE EFFECTS
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Asthma COPD Emphysema Seizure RESPONSE
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Medication SIDE EFFECTS
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Diuretic RESPONSE
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MED Efficacy
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FLUID INTAKE
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Response Caffeine intake
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MEALS
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MEAL PLANNING
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Response BM
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Exercise
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Response Coping skills
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SLEEPING HABITS
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Response Tobacco
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SOBRIETY
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has refills / no appts
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1-800-quit-now
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ADD EXTRA INFO or Dr appts
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**RECEPTIVE to RN visit
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PLAN
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Transitional
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MEDICATIONS
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Response RN Asst/ AIMS test
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