Nur 275 -discharge plan - care plan template PDF

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Summary

nursing school notes...

Description

NUR 275 Discharge Planning/Instruction Sheet SN: ___________________ Patient Initials:__ ____

Room #: ___ ____

Date:__

Admission Date: Discharge Date: Primary Care Physician: Internist Consulting Physician(s): Final Diagnosis What is really happening

rationale (this side- when applicable)

Procedures: (list dates, complications)

History of Present Illness (can refer to dictated/written H&P)

Laboratory/Data (be BRIEF, just the most PERTINENT results that need to be followed after discharge)

Hospital Course (by PROBLEM LIST(Nursing Diagnosis Priority…. NOT BY DATE ) Add top 4-5 diagnoses Add top 4-5 diagnoses rationale

Discharge Medications (MOST IMPORTANT – LIST MEDS THAT ARE DIFFERENT FROM ADMISSION MEDICATIONS FIRST) common additional effects or adverse effects of the medicine or plan- cautions re medicines, e.g., hazards of driving and risky tasks Prescriptions (include taper schedule) (What is different in the hospital than home)& what do you expect for a home med. List meds in the hospital that are different that on admission & consider if they might go home on new meds

Discharge Instructions: 1. Instructions for diagnosis and related comorbidities what is to be done by the patient to help himself get well (or back to baseline/as comfortable as possible considering the circumstances),

2. diet

3. activity

4. cautions what the patient should not do and why- re: driving, work/school release,

5. discharged to: home/nursing facility

6. Survival skills: what to do if any of these should happen, what to do if he fails to improve or worsens, with whom and when he is to follow up number to call or where to go if anything wrong

7. precautions the patient's contacts/family should take

8. call-back number (who to call)

9. Follow up Appointments

10. Code Status INCLUDE: A professional journal article that you have incorporated into the discharge plan and Any handouts given/ or should be given to patient....