INTERDISCIPLINARY PLAN OF CARE AND PATIENT EDUCATION RECORD pg 4 of 5

Transporter Training Handout

Adm Dx: Allergic to contrast dye: ___Yes ___No Use for: procedure off unit/req.prep/traumatic/Inhouse Trans
NONRE-BREATHER O2 MASK VENT PT ON MONITOR þTRANSPORT MONITOR
Situation/Procedure: 65yo Fe CT Abd Situation/Procedure: ICU or Renal scan Cardiac Cath or Stress Test
þNRB 100% þNURSE þMONITOR þVENT þwheelchair Nurse
þstretcher þstretcher

IVF
How will this ON
one be transported? 15
Change toO2 4l NC Can You take pt yourself? Why
pt refuses O2
þO2 4LPM NC How will this one be transported? Change senario to Telemetry
þstretcher Can You take pt yourself? Why7
How will this one be transported? & IVF??
FALL/ELOPEMENT/RESTRAINTS Handoff Communication Detail  Focus: Other Date Sched
Situation/Procedure: PCU pt Support Needs Situation/Procedure: with contrast
þwheelchair Telemetry Transport Monitor O2 @________ IR guided biopsy needle aspiration
young male going for STAT CT Head Nurse Vent _____________________
green arm band on ??? & also Personal Needs Nuc Med  HIDA scan
he yells Deaf Blind HOH Background (Dx/Hx/symptoms r/t situation)
out I’m
Language Barrier_______________________ pain____ _____________________
Sick
Safety Needs Sam  HIDA scan no pain meds/ 8hrs prior
Fall Precautions Restraints Assessment: If with contrast Bun___ Cr___
Confused Elopement (may wander) IR PT___ INR____ PTT____ date_____
How will this one be transported? Physical Needs: Transport Via (init)___correct pt ___correct prep ___correct test
Wheelchair parent lap Recommendation critical value_______
Does he need anything else before? stretcher/bed ______________ Pt tol exam: well refused poor needs_____
Handoff Communication Detail complete return @_____ ini/date
DEAF DOES NOT KNOW ABOUT TEST/OR Transport process using SBAR 3 MONTH OLD CXR/F&U ABD
Situation/Procedure: (circle as appropriate) Handoff communication requires signature Situation/Procedure:
þDeaf þwheelchair 1) when picking up patients go to chart first, it
ALWAYS should go with patient
2) IN CHART TO MULTIDISCIPLINARY
TAB, OPEN TO THIS PAGE OF POC (PLAN OF Care)
3) transport per these instructions, if blank or
seems innacurate ask nurse/chg nurse
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
How will this one be transported? and for what you are taking them How will this one be transported?
5) tech/nurse in dept must check complete or retrun BEORE
Teaching Method Response Date/Initial Teaching Method Response pt returns LEGEND
contrast dye 1 2 3 4 P/F 1 2 3 4 P/F complete upon admission
complete at discharge
MRI 1 2 3 4 P/F 1 2 3 4 P/F Method: 1= Verbal/1:1
2=Demonstration
CT scan 1 2 3 4 P/F 1 2 3 4 P/F 3=Written Material
4= Audio/Visual
NPO 1 2 3 4 P/F 1 2 3 4 P/F Response:
P=Patient F=Family
Colon Prep 1 2 3 4 P/F 1 2 3 4 P/F A=Asked questions
E= Return Demonstrates
Stress Trest 1 2 3 4 P/F 1 2 3 4 P/F B=Poor Attention
N=Needs Reinforcement
Hold Metformin 1 2 3 4 P/F 1 2 3 4 P/F D=Verbalizes Understanding
C=Denial/Resists
Date Signature/Discipline Initals Date Signature/Discipline Initals Teaching Goals: P or F is able to D or
patient label
ouse Transfer

ation

tuation)

_ Cr___

correct test
_______
ds_____

ischarge

e to D or E
 INTERDISCIPLINARY PLAN OF CARE &
update Q 24 hours PATIENT/FAMILY EDUCATION RECORD update Q 24 hours
Section I) PATIENT EDUCATIONAL NEEDS ASSESSMENT (circle appropriate responses)
Readiness to learn: Educational Level: (circle highest grade completed) Support System: Preferred Method:
& Interested K 1 2 3 4 5 6 7 8 9 10 11 12 Technical/Vocational spouse family Verbal (1:1) Written Video
& Uninterested College 1 2 3 4 Master's_______ Doctorial friend none Demonstration No Pref.
& Barriers Speech/Language________________ Visual Hearing Cultural/Religious Cognitive Emotional
(circle all that apply) Educational Level Literacy Financial Pain Physical Medical Equipment Denial
Section II) BASIC PATIENT SAFETY NEEDS Priority H=High, M=Medium, L=Low
þ 1. FOCUS: KNOWLEDGE DEFICIT þ 2. FOCUS: COMFORT/PAIN þ 3. FOCUS: SAFETY
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_______ Initials______
H M L
Interventions: Interventions: Interventions:
þ     Provide for privacy
þ     Provide patient education handbook þ    Assess and meet personal needs P&P CP3012 þ  Identify patient by name & DOB P&PAP2003
þ    Provide MCM patient visitor guide þ    Assess pain every shift and PRN þ   Visual assessment as per policy
þ     Orient to room and hospital environment þ    Utilize appropriate pain scale þ  Maintain JCAHO Safety Goals     
þ     Instruct on call light use        Use alternative therapies for pain relief þ  Fall risk appraisal (ADM, Daily, Conditionr)
      Assess pain medication effectiveness
þ     Instruct on phone use & room telephone number -Score <15 use: Universal Safety
þ Primary Dx:___________________________          Document each episode of pain -Score =/>15 & pediatrics(13 & under) use:
   _______________________________        Notify physician of unrelieved pain -High Risk Fall Protocol P&P CP3008
Teaching Method Response Date/Initial Teaching Method Response Date/Initial -green armband -observe Q1hr
Pt Ed Hndbk 1 2 3 4 P/F Scale 0-10 1 2 3 4 P/F -bed alarm activated -up with assist
Orient to Rm 1 2 3 4 P/F Management 1 2 3 4 P/F -BRP Q4hr, & Q2hr if incontinent/diarrhea
Call light 1 2 3 4 P/F Rx: 1 2 3 4 P/F -half side rails up -pt/family teaching
MCM Guide 1 2 3 4 P/F Rx: 1 2 3 4 P/F -care with pain meds & sedatives
Desired Outcome (Goals) Goal Met Desired Outcome (Goals) Goal Met þ   Assess and meet activity needs
þ Verbalizes understandingof Primary Dx
Y N þ Acceptable pain/discomfort level Y N þ   Assess and meet age specific needs
þDescribes Health Concern/Coping Method
Y N þVerbalizes understanding pain/scale/meds Y N þ  Reconcile medications across continuum
__Verbalize Pre/Intra/Post Surgical Plan Y N __ Pain relief with medication Y N  Non-Behavioral restraints per policy
Teaching
Plan if not Met: ________________________________Plan if not Met: ________________________________ Method Response Date/Initial

Resolved by ________________ Date _________ Resolved by ________________ Date _________ Name/DOB 1 2 3 4 P/F
þ 4 . FOCUS: INFECTION CONTROL þ 5. FOCUS: COMMUNICATION Fall Risk 1 2 3 4 P/F
Initiated by _______________ Date_______
H M L Initiated by _________ Date__________ H M L Med Recon 1 2 3 4 P/F
Priority change Date_______ Initials______
H M L Priority change Date_______ Initials______
H M L Stop Smoke 1 2 3 4 P/F
Interventions: þ Isolation if indicated Interventions:    Obtain interpreter as needed 1 2 3 4 P/F
þ Good hand hygiene (patients,visitors And staff)
þ  Assess level of communication using age 1 2 3 4 P/F
þ  Implement safety goals as indicated specific/culturaly acceptable interventions Desired outcomes (Goals) Goal Met
þ  Vital signs as ordered     Use communication board þ No injury Y N
þ  Notify IC nurse if appropriate     Use pad and pencil/marker þ No patient harm due to falls Y N
    Use interpreter phone (1-888-449-5956) þ Medications reconciled
þ   Notify MD of critical/abnormal labs, vital signs Y N
    Sign language interpreter (call House Supervisor)
þ   Monitor lab/cultures and/or antibiotics as ordered Plan if not Met: __________________________
Teaching Method Response Date/Initial Teaching Method Response Date/Initial Resolved by _____________ Date ________
Wash Hands 1 2 3 4 P/F Interpreter 1 2 3 4 P/F LEGEND
Isolation 1 2 3 4 P/F Com Board 1 2 3 4 P/F complete upon admission
complete at discharge
S/S Infection 1 2 3 4 P/F 1 2 3 4 P/F Method:1= Verbal/1:1
2=Demonstration
Desired outcome (Goal) Goal Met Desired outcome (Goals) Goal Met 3=Written Material
4= Audio/Visual
__No S/S of infection Y N þEffective Communication plan established
Y N Response:
P=Patient F=Family
__TPR within normal limits for patient Y N __Verbalizes understanding of all teaching
Y N A=Asked E=
questions
Return Demonstrates
__No redness/drainage wound/insertion Ysites
N _ ______________________ Y N B=Poor Attention
N=Needs Reinforcement
Plan if not Met: ___________________________________
Plan if not Met: _______________________________D=Verbalizes Understanding
C=Denial/Resists
Resolved by ________________ Date _________ Resolved by ________________ Date _________ Teaching Goals: P or F is able to D or
Date Signature/Discipline Initals Date Signature/Discipline Initals
patient label
 pg 1 of 5
INTERDISCIPLINARY PLAN OF CARE AND PATIENT EDUCATION RECORD pg 2 of 5
Section III) PATIENT PHYSIOLOGICAL & SUPPORT NEEDS Priority H=High, M=Medium, L=Low
 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 _______________ Date_______
H M L
Priority change Date_______ Initials______
H M L Priority change Date_______ Initials______
H M L Priority change Date_______ Initials______
H M L
Interventions:          Dietician consult Interventions: Interventions:
  Implement protocol for Braden <12 (waffel overlay)     Assess RR & breath sound every shift and PRN  Monitor BP, P & cardiac rhythm per unit policy
 Dietician consult     Monitor O2 Sats/ABGs & PRN, Routine: M/S tid, ICU Q1hr, PCU Q2hr,
 Turn patient frequently     Encourage C/DB exercises ER/WC/Surg Sxs per patient condition
  Keep skin clean and dry     Suction airway as needed   Monitor I & O (Pedi/IVF/CHF/foley/Diuretics)
  Specialty mattress as indicated     Encourage appropriate activity   Daily wts by night shift, chart on graphic
  Increase activity as tolerated     O2 and respiratory treatments as ordered   Measure hemodynamic status
   Consult WOCN (Wound Care Nurse)     Notify physician of condition changes/critical  values
Monitor ordered labs: protocols per unit policy
   Dressing changes or treatments as ordered     Vents: HOB up 30-40 degrees, oral care, þsedation   Notify physician of condition changes/crit vals
Teaching Method Response Date/Initial Teaching Method Response Date/Initial Teaching Method Response Date/Initial
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 mattres 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 Met
__No or improved existing skin breakdown
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 patientY N
__Surgical wound healing w/o complications
Y N __Bilateral breath sounds clear Y N __Decrease in ectopy dysrhythmias
Y N
__Verbalize understanding/demonstrateYcare
N __Improved cough, airway clearing Y N __Verbalizes understanding of ed.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)  10. FOCUS: RENAL/FLUID VOLUME  11. FOCUS: PHARMACY
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_______ Initials______
H M L
Interventions:  Consult PT Interventions: Accurate I& O/daily weights Medication review:
  Turn, cough and deep breath at a minimum of   qObserve
2 hrs for changes in BP &pulse
   Active/passive ROM q shift and prn    Assess skin turgor / mucous membranes/edema Interventions:
   Instructed on use of walker, cane, crutches, etc.
   Monitor labs/notify physician of critical/abn values
Teaching Method Response Date/Initial Teaching Method Response Date/Initial Teaching Method Response Date/Initial
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 Met
__No complications related to immobilityY 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 WNL Y N __Verbalizes understanding of ed.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 _______________ Date_______
H M L
Priority change Date_______ Initials______
H M L Priority change Date_______ Initials______
H M L Priority change Date_______ Initials______
H M L
Interventions:  Monitor bowel movements daily
Interventions:  Accurate I & O documented Interventions:Dietary / SLP consult prn
   Assess bowel sounds q shift and per condition Assess abdomen/BS q shift and per condition   Monitor meals/ TPN/ TF as needed
  Check for abdominal distention/impaction as needed
 Monitor H&H/lytes & Notify physician of abn/crit
  Encourage
values fluids, monitor I & O, daily weight
  Stool softners/laxatives/push flds/activity as ordered
 Monitor/administer IVF/transfuse/po flds as ordered
  Assess age/culture specific dietary needs
Teaching Method Response Date/Initial Teaching Method Response Date/Initial Teaching Method Response Date/Initial
1 2 3 4 P/F 1 2 3 4 P/F lo Na/lo chol1 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 Met
__Verbalizes understanding bowel program
Y N __No c/o nausea, vomiting, diarrhea Y N __Weight maintain/loss/gain need Ymet
N
__Bowel sounds present/soft formed stools
Y N __Hemodynamically stable/no s/s GI bleed
Y N __Nutritional/healing needs met 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 5
Section III) PATIENT PHYSIOLOGICAL & SUPPORT NEEDS Priority H=High, M=Medium, L=Low
 15.FOCUS: PERIPHERAL VASCULAR 17.FOCUS: ENDOCRINE  16.FOCUS: NEUROLOGICAL
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_______ Initials______
H M L
Interventions: Interventions: Interventions:
 Assess q shift: edema/warmth/color/tingling/numbness
 Assess LOC/orientation/skin integrity   Neuro checks as ordered `
 Check peripheral pulses q shift & PRN  Monitor ordered lab values, I&O, daily weights  Notify physician of condition change
 Assess ROM  Dietary consult/diet instructions as ordered   Monitor ordered lab values
 Measurement of extremities as necessary   Notify Physician of condition changes/critical or abn
  Notify physician of changes in mentation

 Notify physician of significant change lab values/vit neuro checks, critical values.
Teaching Method Response Date/Initial Teaching Method Response Date/Initial Teaching Method Response Date/Initial
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 Met
__Skin W/D with capillary refill <3 sec Y N __Maintains stable LOC Y N ___Awake, alert & oriented x3 Y N
__Normal CMS and pulses present Y N __Ordered lab values in acceptable range
Y N ___Mental status improved or Y N
__Normal or improved motor function Y N __Has understanding of dz/interventions
Y N status quo
__Other_________________________ Y N __Able to manage self-care at home Y N ___Other__________________ Y N
Plan if not Met: ___________________________________
Plan if not Met: ___________________________________
Plan if not Met: ____________________________
Resolved by ________________ Date _________ Resolved by ________________ Date _________ Resolved by ________________ Date _______
 17. FOCUS: OB/GYN  18. FOCUS: EMOTIONAL/SPIRITUAL FOCUS: DISCHARGE PLANNING
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_______ Initials______
H M L
Assess patients knowledge of labor Interventions:
Interventions:     Family as support Interventions:
Pain management during labor and post partum  Explain all tests/procedures in age specific manner
Assess support system/family support
Maternal and neonatal education beginning on adm.
 Quiet environment Assess for financial resources
Monitor hemodynamics of mother/neonate during Notify
LDRP Appropriate referrals to home health
MD of need for sedative/sleeper if indicated
Observe for positive bonding  Allow to verbalize fear Appropriate referrals for medication assistance
Notify physician of abnormalities  Spiritual supportGrief Counseling as necessary Appropriate referrals for F/U care per pt needs
Teaching Method Response Date/Initial Teaching Method Response Date/Initial Teaching Method Response Date/Initial
1 2 3 4 P/F Relaxation 1 2 3 4 P/F Hospice 1 2 3 4 P/F
1 2 3 4 P/F 1 2 3 4 P/F outpt option 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 outcomes (Goals) Goal Met Desired outcomes (Goals) Goal Met Desired outcome (Goals) Goal Met
__Pain managed during labor &PP periodY N ___Relaxes posture & facial expression Y N __Dschrg to appropriate Level of Care
Y N
__Verbalizes understanding of labor process
Y N ___Verbalizes less anxious/fearful Y N __Ancillary Dept. Invovled in plan Y N
__Verbalizes understanding of newborn Y
care
N ___Demonstrates good coping skills Y N __Pt/SO verbalizes understanding Y N
__Delivery of infant w/o complications Y N __ Other_________________ Y N of home meds, treatments, refferals,
__Good bonding of mother and neonateY N appointments, &______________
Plan if not Met: ___________________________________
Plan if not Met: ___________________________________
Plan if not Met: ____________________________
Resolved by ________________ Date _________ Resolved by ________________ Date _________ Resolved by ________________ Date _______
Extra Patient/Family Education Record Space LEGEND
Teaching Method Response Date/Initial Teaching Method Response Date/Initial complete upon admission
complete at discharge
1 2 3 4 P/F Discharge 1 2 3 4 P/F Method:1= Verbal/1:1
2=Demonstration
1 2 3 4 P/F CHF packet 1 2 3 4 P/F 3=Written Material
4= Audio/Visual
1 2 3 4 P/F organ donat 1 2 3 4 P/F Response:
P=Patient F=Family
1 2 3 4 P/F 1 2 3 4 P/F A=Asked E=
questions
Return Demonstrates
1 2 3 4 P/F 1 2 3 4 P/F B=Poor Attention
N=Needs Reinforcement
 1 2 3 4 P/F 1 2 3 4 P/F D=Verbalizes Understanding
C=Denial/Resists
Date Signature/Discipline Initals Date Signature/Discipline Initals Teaching Goals: P or F is able to D or

patient label

INTERDISCIPLINARY PLAN OF CARE AND PATIENT EDUCATION RECORD pg 4 of 5

Section IV) SUPPORT & Handoff Communication (SBAR Methodology) S/B=nurse A=nurse/tech R=tech
Adm Dx: Allergic to contrast dye: ___Yes ___No Use for: procedure off unit/req.prep/traumatic/Inhouse Tran
 Focus: Radiology Date Sched Focus: Radiology Date Sched  Focus: Nuc Med Date Sch
Situation/Procedure: with contrast Situation/Procedure: with contrast Situation/Cardiac Stress Test
CT MRI : head abd_______ ______________ CT MRI : head abd_______ ______________  Adenosine/thallium  Dobutaine/thallium
Sono(US): R/L LE abd_____ _____________ Sono(US): R/L LE abd_____ _____________  Persantine/thallium  _____________
UGI LGI(BE) Hypaque _____________ UGI LGI(BE) Hypaque _____________  Exercise (not a nuc med scan
Background:(Hx r/t situation/presenting symptoms)
Background:(Hx r/t situation/presenting symptoms)
Background: Cardiac Hx/symptoms
pain____ LOC Trauma _____________ pain____ LOC Trauma _____________ CP MI Stents/CVI CABG______
claustrophobia/anxiety Pre-Med w/____________
claustrophobia/anxiety Pre-Med w/____________
Surgical Clearance _________________
x MRI: ICD  prosthesis<___wks metal_______x MRI: ICD  prosthesis<___wks metal______Weight______lbs/kg IV_________@___ml/hr
Assessment: If with contrast Bun___ Cr___ Assessment: If with contrast Bun___ Cr___ Assessment: If with contrast Bun___ Cr___
(initial)__/__correct pt __/__ correct prep __/__correct
(initial)__/__correct
test pt__/__ correct prep__/__correct
__/__correct
test pt__/__correct prep__/__correct test
Recommendation(s) critical value__________Recommendation(s) critical value_________Recommendation(s)critical value_______
Pt tol exam: well refused poor needs__________
Pt tol exam: well refused poor needs_________
Pt tol exam: well refused poor needs______
complete return @_____ initial/date complete return @_____ initial/date completereturn @___ initial/date
Focus: Radiology Date Sched Handoff Communication Detail  Focus: Other Date Sched
Situation/Procedure: with contrast Support Needs Situation/Procedure: with contrast
CT MRI : head abd_______ ______________ Telemetry Transport Monitor O2 @________IR guided biopsy needle aspiration
Sono(US): R/L LE abd_____ _____________ Nurse Vent _____________________
UGI LGI(BE) Hypaque _____________ Personal Needs Nuc Med  HIDA scan
Background:(Hx r/t situation/presenting symptoms)
Deaf Blind HOH Background (Dx/Hx/symptoms r/t situation)
pain____ LOC Trauma _____________ Language Barrier_______________________ pain____ _____________________
claustrophobia/anxiety Pre-Med w/____________
Safety Needs  HIDA scan no pain meds/ 8hrs prior
x MRI: PM/ICD  prosthesis<_wks metal______Fall Precautions Restraints Assessment: If with contrast Bun___ Cr___
Assessment: If with contrast Bun___ Cr___ Confused Elopement (may wander) IR PT___ INR____ PTT____ date_____
Physical
(initial)__/__correct pt __/__ correct prep __/__correct test Needs: Transport Via (init)___correct pt ___correct prep ___correct test
Recommendation(s) critical value__________Wheelchair parent lap Recommendation critical value_______
Pt tol exam: well refused poor needs__________
stretcher/bed ______________ Pt tol exam: well refused poor needs_____
complete return @_____ initial/date Handoff Communication Detail complete return @_____ ini/date
 Focus In-House Transfer  Focus In-House Transfer Focus In-House Transfer
Situation/Procedure: (circle as appropriate) Situation/Procedure: (circle as appropriate)Situation/Procedure:
From: ICU ERhold PCU1 PCU3 M/S__ From: ICU ERhold PCU1 PCU3 M/S__ From: ICU ERhold PCU1 PCU3 M/S__
To: ICU ERhold PCU1 PCU3 M/S__ Tele
To: ICU ERhold PCU1 PCU3 M/S__ Tele
To: ICU ERhold PCU1 PCU3 M/S__ Tele
Background (Dx/Brief Hx/Procedures done) Background (Dx/Brief Hx/Procedures done) Background (Dx/Brief Hx/Procedures done)
Dx: AMI CHF Pneu (core measure protocol initiated)
Dx: AMI CHF Pneu (core measure protocol initiated)
Dx: AMI CHF Pneu (core measure protocol)
RF DM GI Bleed CP CVA __________________
RF DM GI Bleed CP CVA __________________
RF DM GI Bleed CP CVA __________
Assessment: TPR________ B/P_____ Assessment: TPR________ B/P_____ Assessment: TPR________ B/P_____
LBM______ IV site________ Fld________ rate____ml/hr
LBM______ IV site________ Fld________ rate____ml/hr
LBM_____ IV site______ Fld_______ rate___ml/hr
A&O X ____ incont foleySkin:_______ A&O X ____ incont foleySkin:_______ A&O X ____ incont foley
Skin:_______
Recommendation(s) Q&A Recommendation(s) Q&A Recommendation(s) 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 LEGEND
contrast dye 1 2 3 4 P/F 1 2 3 4 P/F complete upon admission
complete at discharge
MRI 1 2 3 4 P/F 1 2 3 4 P/F Method:1= Verbal/1:1
2=Demonstration
CT scan 1 2 3 4 P/F 1 2 3 4 P/F 3=Written Material
4= Audio/Visual
NPO 1 2 3 4 P/F 1 2 3 4 P/F Response:
P=Patient F=Family
Colon Prep 1 2 3 4 P/F 1 2 3 4 P/F A=Asked E=
questions
Return Demonstrates
Stress Trest 1 2 3 4 P/F 1 2 3 4 P/F B=Poor Attention
N=Needs Reinforcement
Hold Metformin 1 2 3 4 P/F 1 2 3 4 P/F D=Verbalizes Understanding
C=Denial/Resists
Date Signature/Discipline Initals Date Signature/Discipline Initals Teaching Goals: P or F is able to D or

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 Needs
Date Signature/Discipline Initals Date Signature/Discipline Initals
patient label
OB P&PAP2003

y, Conditionr)
al Safety
3 & under) use:

erve Q1hr
with assist
nent/diarrhea
amily teaching

ross continuum

__________

at discharge

s able to D or E
 per unit policy
1hr, PCU Q2hr,

ey/Diuretics)
on graphic

s per unit policy

hanges/crit vals

____________
Date _______

____________
Date _______

O, daily weight
tary needs
____________
Date _______

____________
Date _______

ation assistance
re per pt needs

____________
Date _______

at discharge
s able to D or E

atic/Inhouse Transfer

e/thallium

_@___ml/hr
un___ Cr___
_/__correct test
lue_______
needs______

spiration

r/t situation)

8hrs prior
un___ Cr___

p ___correct test
lue_______
needs_____

U3 M/S__
M/S__ Tele
dures done)
re protocol)

_ rate___ml/hr

____ To______

at discharge
s able to D or E
Instructions: INTERDISCIPLINARY CARE PLAN & PATIENT/FAMILY EDUCAT
A) The Basics
1) Read these instructions before attempting to complete this form to ensure proper
2) 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 convenie
shading are required at admission, areas of light-gray shading are required at discharge on any focus init
4) The care plan is required to be initiated upon admission and updated and daily by various regulatory agencie
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 issues) and e
standards (standards of care are what a reasonable and prudent professional is accountable to do based
Select the Focuses for which the patient requires intervention and teaching this admission: Initiate the ap
and dating next to "initiated by:" select priority H=high, M=Medium, L=low, Select appropriate intervent
At discharge each focus are that has been initiated must be resolved, cirlde Y=Yes indicating goals met i
is true. Circle N=No if it is false and next to "plan if not met" write what the follow-up plan is: "NH to___"
b) an interdisciplinary patient/family education record: ALL education should be documented in th
are responsible that the patient/caregiver receives the education necessary to manage their care includi
Interventions to relieve symptoms, Procedures (ambulatory devices, equipment, wound care etc), Diet, P
of Refusal of care, etc. Educational items that are required or are frequently used have been added for y
then (see legend) circle method, patient and or family, add the letter(s) that describe the patient's/family
c) a hand off communication tool/record: this is located on page 4 and on the addendum page. This
the communication to ensure patient safety when the patient is off of the unit and out of the care of the
i) radiology exams off unit that requiring preps, these require safisticated communication between discip
ii) in house transfers from any unit to any other unit: since care and charge nurses are changing
iii) situations meeting the statement in "5c". (handoff communication during change of shift, pre-post pro
6) This form is interdisciplinary (all disciplines: Nursing/PT/SLP/RT/Dietician/Rx/Case Management/Social Work et
should document on the form as appropriate for that disciplines interventions, education etc. Each time Y
place your initials, signature and date at the bottom of the form in the indicated box. (on one page is all
B) Section I Patient Educational Needs Assessment Section (page 1) & Section V Age Specific Care Ne
1) Complete at the time of admission with the Admission Assessment (M/S admit nurse, ICU/PCU/ER hold primary n
responses for each topic. Page 5 initial the box in the focus section appropriate for the patient, complete
2) Readiness to learn: circle either "interested" or "uninterested" as appropriate, if there are any barriers to learnin
circle all baariers the patinet/family has, next to Speech/Language indicate primary language, or things l
C) Section II Basic Patient Safety Needs
1) The areas with the patterned shading are required to be completed upon admission. On Focus 1 indicate primar
2) Each of these focuses are basic care needs. Focuses 1-5 contain some interventions basic to all patient's care ne
goals have been preselected and represent MCM basic standards of care. Select other interventions and
3) Teaching should be done as indicated by the pattern shaded areas upon admission by circling method, patient a
letter(s) that describe the patient's/family's
Document
response.
any other teacing done.
5) Focus 3 Safety contains the fall risk interventions, if the score is =/>15 ALL interventions Must be initiated. If the
check the indicated box, and these patients are high risk for falling
D) Section III Patient Physiological and Support Needs
1) Select the appropriate Focuses the correspond to the primary diagnosis, other diagnoses/care issues requiring s
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 slots at t
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 documentation to re
with the acception of pharmacy and discharge planning. See A5b above.
F) Update Daily:
1) Review each focus initiated and if any issues are resolved indicate by circling Goal Met "Y=Yes" (note focus 1-5
2) Add new focus areas: use assessment, added medications, test results and new consults as suggetions for chan
3) Change the priority level according to patient needs by initialing/dating/circling new priority level next to "Priotit
G) Section IV Patient Support and Handoff Communication Needs
1) Radiology/Nuc Med/Other: For the types of procedures described in A5c above the care/charge nurse assigned
S=Situation, B=Background, and teahing of the proedure and any prep (hand out "radiology exams"unde
A=Assessment will have lab value added as indicated, and at the time the patient is taken to radiology th
correct pt/prep/test, the radiology tech will initial the same when pt is in department before the procedur
 filled out before the patient returns to floor as indicated, the tech will initial and date, and fill out signaur
2) In House Transfer all sections will be filled out by transfering nurse, when the patient arrives at new unit both nu
 Y EDUCATION RECORD

sure proper completion

or your convenience. Areas of patterned

on any focus initiated.
gulatory agencies. Nursing is responsible.

re issues) and each disciplines intervention

ble to do based on liscensure & training)
n: Initiate the appropriate focuses by initialing
priate interventions/goals. /
ating goals met if the Goal statement
n is: "NH to___" D/c to LTAC" etc.
ocumented in the "teaching" sections. YOU
heir care including: Diagnosis, Medications,
care etc), Diet, Plan of Care, Consequences
een added for you, add others as needed
e patient's/family's response, date & initial
dum page. This document encompasses
the care of the primary/charge nurse. Such as:
n between disciplines
hanging
hift, pre-post procedures are NOT done here)
t/Social Work etc.) involved in the case
etc. Each time YOU document on the form
n one page is all that is necessary)
ecific Care Needs (page 5)
R hold primary nurse) by circling appropriate
atient, complete signature box at bottom.
arriers to learning please circle "barriers" and
uage, or things like aphasic.

indicate primary diagnosis.

patient's care needs. These interventions and
terventions and goals as needed. See A5a
method, patient and or family, add the

e initiated. If the patient requires restraints

sues requiring significant interventions and

aching slots at the bottom of page 3

umentation to resolve each Focus area

(note focus 1-5 are NOT resolved until D/C.

getions for changes to the plan.
el next to "Priotity change"

nurse assigned to the patient will document

ogy exams"under procedures on Z-drive)
en to radiology the care/charge nurse initials
ore the procedure. R=Rcommendation will be
d fill out signaure section at bottom of page.
new unit both nurses will initial as indicated.
 INTERDISCIPLINARY PLAN OF CARE
CASE CONFERENCE RECORD
DATE:______________________ ANTICIPATED DISCHARGE DATE:________________________
NEED AREA TREATMENT PLAN VARIANCES DISCHARGE PLAN
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
INTERDISCIPLINARY PLAN OF CARE AND PATIENT EDUCATION RECORD ADDENDUM
Section IV) SUPPORT & Handoff Communication (SBAR Methodology) S/B=nurse A=nurse/tech R=tech
Adm Dx: Allergic to contrast dye: ___Yes ___No Use for: procedure off unit/req.prep/traumatic/Inhouse Tran
 Focus: Radiology Date Sched Focus: Radiology Date Sched  Focus: Nuc Med Date Sch
Situation/Procedure: with contrast Situation/Procedure: with contrast Situation/Cardiac Stress Test
CT MRI : head abd_______ ______________ CT MRI : head abd_______ ______________  Adenosine/thallium  Dobutaine/thallium
Sono(US): R/L LE abd_____ _____________ Sono(US): R/L LE abd_____ _____________  Persantine/thallium  _____________
UGI LGI(BE) Hypaque _____________ UGI LGI(BE) Hypaque _____________  Exercise (not a nuc med scan
Background:(Hx r/t situation/presenting symptoms)
Background:(Hx r/t situation/presenting symptoms)
Background: Cardiac Hx/symptoms
pain____ LOC Trauma _____________ pain____ LOC Trauma _____________ CP MI Stents/CVI CABG______
claustrophobia/anxiety Pre-Med w/____________
claustrophobia/anxiety Pre-Med w/____________
Surgical Clearance _________________
x MRI: ICD  prosthesis<___wks metal_______
x MRI: ICD  prosthesis<___wks metal______ Weight______lbs/kg IV_________@___ml/hr
Assessment: If with contrast Bun___ Cr___ Assessment: If with contrast Bun___ Cr___ Assessment: If with contrast Bun___ Cr___
(initial)__/__correct pt __/__ correct prep __/__correct
(initial)__/__correct
test pt__/__ correct prep__/__correct
__/__correct
test pt__/__correct prep__/__correct test
Recommendation(s) Recommendation(s)
critical value__________ critical value_________Recommendation(s)
critical value_______
Pt tol exam: well refused poor needs__________
Pt tol exam: well refused poor needs_________
Pt tol exam: well refused poor needs______
complete return @_____ initial/date complete return @_____ initial/date completereturn @___ initial/date
 Focus: Other Date Sched  Focus: Other Date Sched  Focus: Other Date Sched
Situation/Procedure: Situation/Procedure: Situation/Procedure:

Background:(Hx r/t situation/presenting symptoms)

Background:(Hx r/t situation/presenting symptoms)
Background (Dx/Hx/symptoms r/t situation)

Assessment: Assessment: Assessment:

Recommendation(s) Recommendation(s)
critical value__________ critical value_________Recommendation critical value_______

initial/date initial/date initial/date

 Focus In-House Transfer  Focus In-House Transfer  Focus: Other
Situation/Procedure: (circle as appropriate)Situation/Procedure: (circle as appropriate)Situation/Procedure:
From: ICU ERhold PCU1 PCU3 M/S__ From: ICU ERhold PCU1 PCU3 M/S__
To: ICU ERhold PCU1 PCU3 M/S__ Tele
To: ICU ERhold PCU1 PCU3 M/S__ Tele
Background (Dx/Brief Hx/Procedures done) Background (Dx/Brief Hx/Procedures done) Background (Dx/Brief Hx/Procedures done)
Dx: AMI CHF Pneu (core measure protocol initiated)
Dx: AMI CHF Pneu (core measure protocol initiated)
RF DM GI Bleed CP CVA __________________
RF DM GI Bleed CP CVA __________________
Assessment: TPR________ B/P_____ Assessment: TPR________ B/P_____ Assessment:
LBM______ IV site________ Fld________ rate____ml/hr
LBM______ IV site________ Fld________ rate____ml/hr
A&O X ____ incont foleySkin:_______ A&O X ____ incont foleySkin:_______
Recommendation(s) Q&A Recommendation(s) Q&A Recommendation(s) Q&A
Orders Orders
Date__________ Initials From_______ To______ Date__________ Initials From_______ To______ initial/date
Teaching Method Response Date/Initial Teaching Method Response Date/Initial LEGEND ADDENDUM
contrast dye 1 2 3 4 P/F 1 2 3 4 P/F complete upon admission
complete at discharge
MRI 1 2 3 4 P/F 1 2 3 4 P/F Method: 1= Verbal/1:1
2=Demonstration
CT scan 1 2 3 4 P/F 1 2 3 4 P/F 3=Written Material
4= Audio/Visual
NPO 1 2 3 4 P/F 1 2 3 4 P/F Response:
P=Patient F=Family
Colon Prep 1 2 3 4 P/F 1 2 3 4 P/F A=Asked E=
questions
Return Demonstrates
Stress Trest 1 2 3 4 P/F 1 2 3 4 P/F B=Poor Attention
N=Needs Reinforcement
Hold Metformin 1 2 3 4 P/F 1 2 3 4 P/F D=Verbalizes Understanding
C=Denial/Resists
Date Signature/Discipline Initals Date Signature/Discipline Initals Teaching Goals: P or F is able to D or
patient label
matic/Inhouse Transfer

e/thallium

_@___ml/hr
Bun___ Cr___
__/__correct test
ue_______
needs______

r/t situation)

ue_______

dures done)

t discharge

s able to D or E