Nursing Templates

Insulin Adjustment - Medication Management Note, Vr. 2.
0
Created Approved Approved Revised By: Date: By: Date: L. Dale / 5/10/06 T. Niu 6/5/08 M. Gillard INSULIN ADJUSTMENT - MEDICATION MANAGEMENT NOTE, Vr. 2.0 ASSESSMENT: Received Blood Glucose Levels from patient. Current insulin dose:(type, dose, time) <____> NURSING IMPRESSION: Needs insulin adjustment per protocol (explain): <____> Creation Date: 5/10/06
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Revised By: D. Brown C. Davies
PLAN: l. New dose: <____> 2. Call/fax Blood Glucose Levels to: <____> 3. Call if une xplained Blood Glucose Level > 300 mg/dl or < 70 mg/dl more than two times in one week. <____Patient restated appropriate times to contact nurse or physician. Related URL or References:
Lipid Management for Diabetic Patients Medication Management Note, Vr. 1.0
Creation Date: 10/7/08
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Created Approved Approved Revised By: Date: By: Date: Patty Lindsay-Carr 10/7/08 D. Kowalczyk and Diane Brown LIPID MANAGEMENT FOR DIABETIC PATIENTS Medication Management Note, Vr. 1.0 SUBJECTIVE: Current Medications/Dose and date started per patient: <____> OBJECTIVE: NURSING ASSESSMENT: <____> Blood pressure: <____MostRecentBloodPressure____> Weight: <____MostRecentWeight(e)____> BMI <____MostRecentBMI____> LDL/Date <____> HgA1C/Date <____> NURSING IMPRESSION: Elevated LDL PLAN Per D.O.I.T Statin Protocol Goal: LDL Cholesterol less than 100 mg/dl ALT less than 70 IU/L [ ] LDL greater than 100 and [ ] ALT less than 70 IU/L: Increased dose on <____> (medication) from <____> to <____> per prot ocol/algorithm
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ALT greater than 70 IU/L: PCP notified Patient at maximum dose; Referred to PCP Goal achieved: LDL less than 100: recheck LDL in 1 year Simplified drug regimen to fewest number of pills.
In 1-2 months Date: <____> [ ] Check cholesterol and CHD profile 1 -2 months after dose adjustment/Pt instructed/ Requisition in lab [ ] Notation made in CWN Future Follow Up <___Patient states plan and is in agreement with plan. Related URL or References:
Medication Authorization Status Medication Management Note, Vr. 2.0

Creation Date: 7/24/06 Created By: S. Smith Approved Date: 7/24/06 Approved By: T. Niu Revised Date: 6/5/08
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PRESCRIPTION AUTHORIZATION STATUS Vr. 2.0 AUTHORIZATION STATUS: <____> DATE RECEIVED: <____> RECEIVED BY: <____> APPROVED DATE: <____> DENIED /EXPLANATION: <____> Related URL or References:
Medication Management Note,
Prescription Renewal/Prescription Authorization/Medication Information, Vr. 3.0

Creation Date: 7/24/06 Created By: S. Smith Approved Date: 4/30/07 Approved By: D. Kowalczyk Revised Date: 6/5/08
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PRESCRIPTION RENEWAL/PRESCRIPTION AUTHORIZATION/MEDICATION INFORMATION, Vr. 3.0 Medication Name: <____> Strength: <____> Frequency: <____> Number Remaining: <____> Date of Last Provider Visit: <____> Pharmacy Name: <____> Pharmacy Phone #: <____> Pharmacy Fax #, if known: <____> [] Called/Faxed to Pharmacy Related URL or References:
Prescription Authorization Request Medication Management Note, Vr. 3.0

Creation Date: 7/24/06 Created By: S. Smith Approved Date: 7/24/06 Approved By: T. Niu Revised Date: 6/5/08
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PRESCRIPTION AUTHORIZATION REQUEST - MEDICATION MANAGEMENT NOTE, Vr. 3.0 Patient Name: <____patientName____> Reg #: <____patientReg#____> DOB: <____patientDOB____> Age: <____patientAge____> Gender: <____patientGender____> Patient Daytime Phone (Home) #: <____patientHomePhone____> Patient Alternate Phone (Contact) #: <____patientContactPhone____> Insurance: <____patientInsurance____> Prescription Insurance: <____> Prescript ion Insurance Phone#: <____> Member ID #: <____> Provider (first and last name): <____> Clinic Contact: <____> Clinic Contact Phone: <____> Related URL or References:
Oral and Injectable Anti-Diabetic Medication Management Note, Vr. 1.0

Creation Date: 9/08
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Created Approved Approved Revised Revised By: Date: By: Date: By: Mary Sue Webb 9/08 D. Kowalczyk Patty Lindsay-Carr ORAL AND INJECTABLE ANTI -DIABETIC MEDICATION MANAGEMENT NOTE, Vr. 1.0 ASSESSMENT: CURRENT DIABETIC MEDICATIONS AND DOSE: <____> Length of time on this dose <____> RECENT LAB/VITAL SIGNS : HgA1C: <____> Blood Pressure <____MostRecentBloodPressure____> Weight: <____MostRecentWeight(e) ____> BMI: <____MostRecentBMI____> RECENT SELF BLOOD GLUCOSE TEST RESULTS: Average of Morning Fasting for the Last Week: <____> Average of ac L unch for the Last Week: <____> Average of ac Dinner for the Last Week: <____> Average of Bedtime for the Last Week: <____> Highest Reading for the Last Week: <____> Lowest Reading for the Last Week: <____>
NURSING DIAGNOSIS: [ ] Blood Glucose not within target range of <____> to <____> PLAN: [ ] Patient with overnight or fasting glucose goal of less than 130. [ ] Increased dose of <____> (medication) from <____> to <____> per protocol/algorithm [ ] Side effects and signs and symptoms of hypoglycemia hyperglycemia reviewed with the patient. and
[ ] Patient to check blood glucose <____> times per <____> [ ] Patient to call office if he/she has three blood glucoses over 200 or two blood glucoses under 70 [ ] Patient has adequate supplies to last unt il next clinic visit [ ] Other: <____> <___Patient able to restate instructions and agrees with plan. Related URL or References:
INSTRUCTIONS
Allergy Injection - Patient Instructions, Vr. 2.0

Creation Date: 3/15/06 Created By: T. Thielan Approved Date: 3/15/06 Approved By: K Ford Revised Date: 6/5/08
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ALLERGY INJECTION - PATIENT INSTRUCTION, Vr. 2.0 [ ] Patient [ ] Spouse/ Significant Other [ ] Others (List): <____> PATIENT INSTRUCTION PLAN: Patient will be instructed about Allergy Injections, Action, Side Effects, Medication Management, and Appointments. INSTRUCTIONS GIVEN TODAY: [ ] ACTIONS of ALLERGY INJECTION: Exposes the body to allergens to desensitize the b ody. Does not provide immediate relief. [ ] SIDE EFFECTS OF ALLERGY SHOTS: flushing, periorbitaledema, wheezing or hives, local reaction at site of injection. [ ] WHEN NOT TO GET AN INJECTION: Symptoms of illness, serious medical problems, pregnancy, inc rease in allergy symptoms. [ ] MEDICATIONS: Importance of informing Health Care Professionals of new medications, i.e. Beta Blockers [ ] APPOINTMENTS: Weekly appointments for 8 to 12 months, pending response to Allergy Injection Clinic hours/appointmen ts and locations given Extract reorder process explained [ ] IMMUNOTHERAPY INFORM ATIONPACKET describing potential value and risks of Allergy shots, Received and Reviewed [ ] IMMUNOTHERAPY INFORMATION FORM signed. [ ] Patient/Family restates instructio ns. [ ] Patient will evaluate information and contact Health Care Professional with decision. Related URL or References:
Dry Powder Inhaler - Patient Instructions, Vr.
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2.0
Creation Date: 3/15/06 Created By: T. Thielan Approved Date: 3/15/06 Approved By: K Ford Revised Date: 6/5/08 Revised By: D. Brown C. Davies
DRY POWDER INHALER - PATIENT INSTRUCTION, Vr.2.0 DATE OF LAST PATIENT EDUCATION ASSESSMENT: <____mostRecentPatientEdu____> (Must have been completed within the past 12 months.) LEARNERS PARTICIPATING TODAY [] Patient [ ] Spouse/ Significant Other [ ] Others (Specify): <____> PATIENT INSTRUCTION PLAN: Teach Patient Dry Powder Breath Actuated Inhaler Technique INSTRUCTIONS GIVENTODAY: Patient Instructed on the fol lowing: [ ] Medication:<____> When to use: Daily as directed. Proper inhalation technique: Breathe in, exhale. Then holding the inhaler to their mouth, breathe in steadily and deeply. Hold breath for 10 counts. Rinse mouth after use. Number of Doses avai lable in device and when to get refills Demonstration with inhaler model How to clean inhaler How to store inhaler [ ] Written material given/reviewed with patient [ ] Patient/Family restates instructions and agrees to plan. [ ] Instructed About Resourc es or Number To Call With Ongoing Question(s). Related URL or References:
Epinephrine Auto Injector- Patient Instructions, Vr.1.0

Creation Date: 4/17/08 Created By: T. Thielan Approved Date: 34/17/08 Approved By: D. Kowalczyk Revised Date:
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EPINEPHRINE AUTO -INJECTOR - PATIENT INSTRUCTION, Vr.1.0
LEARNERS PARTICIPATING TODAY: [ ] Patient [ ] Parent/Caregiver [ ] Others (Specify):<____> MEDICATION: [ ] EpiPen [ ] Twinject PATIENT INSTRUCTION PLAN: Instruct patient epinephrine auto -injector dose/technique, causes of anaphylaxis, indications for use, how to store/dispose of and return demonstration. INSTRUCTIONAL INTERVENTIONS IMPLEMENTED TODAY: Patient Instru cted on the following: MEDICATION: [ ] EpiPen [ ] Twinject [ ] Dose: 0.15mg or 0.3mg as ordered Immediately call 911 or seek emergency treatment as indicated May repeat dose in ten minutes if no relief or symptoms return After dose has been given fr om EpiPen, extra medication will remain in syringe that cant be used Additional dose of medication is contained in a syringe within the Twinject after initial injection. Directions are on Twinject injector if second dose of epinephrine is needed. Auto-injector should remain in close proximity in case of need at any given time INDICATION: Allergic reaction of anaphylaxis due to: [ ] Bite or sting from insect [ ] Foods [ ] Medications [ ] Latex [ ] Unknown [ ] Other (specify): <____> [ ] REVIEW OF SYMPTOMS SIGNS AND SYMPTOMS REQUIRI NG USE OF EPINEPHRINE AUTO -INJECTOR: This is for emergency supportive therapy only and is not a replacement or substitute for immediate medical care. Tingling or warm sensation Itching, hives Metallic taste or swelling of the mouth and throat Wheezing, coughing, difficulty breathing Vomiting, diarrhea, or cramping Loss of consciousness [ ] PROPER INJECTION TECHNIQUE Remove auto -injector from hard plastic case and remove safety
cap(s) With dominant hand, g rasp injector and inject through clothing (if necessary), into large thigh muscle Hold for count of ten, auto -injector is spring loaded Massage area for ten seconds If second dose is necessary, follow directions imprinted on the Twinject auto -injector. EpiPen auto -injectors are single dosed and therefore, should remain together as dispensed. [ ] STORAGE AND DISPOSAL OF AUTO -INJECTORS Protect from light, store at room temperature, protect from freezing, do not refrigerate Observe expiration dates or discolored fluid in injector, replace as necessary Dispose of in approved sharps collector [ ] COMMON SIDE EFFECTS: Anxiety, apprehensiveness, restlessness Weakness, tremor, dizziness, headache, sweating Irregular heartbeat, nausea, vomiting, bre athing difficulty [ ] WRITTEN MATERIAL, DV D, AUTO-INJECTOR TRAINER GIV EN/REVIEWED WITH PATIENT [ ] Patient able to state Indication for Medication, Signs and Symptoms requiring usage, storage and disposal and common side effects. [ ] Patient demonstra ted proper Injection Technique DISPOSITION: [ ] Re-Instruct [ ] Review [ ] Refer to Ordering Provider with further questions [ ] Instructed about resources or number to call with ongoing questions Related URL or References:
Gynecology Procedure Patient Discharge Instructions, Vr. 1.0

Creation Date: 4/10/09 Created By: Rochelle Slay Cheri Rice Approved Date: 4/27/09
No response
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Approved By: HIM Billing
Revised Date:
Revised By:
GYNECOLOGY PROCEDURE PATIENT DISCHARGE INSTRUCTIONS, Vr. 1.0 LEARNERS PARTICIPATING TODAY: [ ] Patient [ ] Spouse [ ] Other (specify): <____>
PROCEDURE: [ ] Cervical Loop Electrosurgical Excision Procedure [ ] Cervical Laser [ ] Conization of the Cervix [ ] Vaginal Laser INSTRUCTION GIVEN TODAY: [ ] You have received a local (cervical) anesthetic; the effects will wear off within several hours [ ] You have received anesthesia for your procedure. Do not sign any legal forms, drive or operate machinery for 24 hours. [ ]Physical activity as tolerated [ ] Avoid vaginal douching, sexual intercourse and tampons for 2-4 weeks as they increase your risk of bleeding and/or infection [ ] You may have a bloody vaginal discharge with black specks for about two days. [ ] You may have a clear, pinkish, or brownish vaginal discharge for approximately 2 -4 weeks. [ ] No special diet needed; resume your previous diet. [ ] may [ ] [ ] [ ] If your physician recommends taking pain medication you take: Ibuprofen 600 mg. orally every 6 -8 hours Acetaminophen 650 mg. orally every 4 hours Prescription medication as ordered by provider
CONTACT YOUR HEALTH CARE PROVIDER IF YOU DEVELOP THE F OLLOWING: [ ] Vaginal bleeding heavier than a normal menstrual period [ ] Foul smelling vaginal discharge [ ] Abdominal or vaginal pain not relieved by your pain medication [ ] Temperature over 100.4 degrees Fahrenheit MONDAY THROUGH FRIDA Y 8 AM-4:30 PM: Gynecology -Oncology clinic (734) 647 -8906 AFTER OFFICE HOURS C ONTACT: [ ] Gynecology resident on call at (734) 936 -6267 [ ] Gynecology -Oncology answering service at (734) 4 77-6437 Follow-up: [ ] Post procedure appointment in 2 -8 weeks, or as advised by your physician. To confirm that post -op appointment has been scheduled, call 734 -647-8906.
[ ] Patient/Family restates instructions and agrees with plan. Related URL or References:
Liver Biopsy Patient Prep Instructions, Vr. 1.0

Creation Date: 4/16/08 Created By: Lisa S. Sylvest Approved Date: 4/16/08 Approved By: D. Kowalczyk Revised Date:
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LIVER BIOPSY PATIENT PREP INSTRUCTIONS, Vr. 1.0 Ordering Provider: <____> Date Liver Biopsy Scheduled: <____> PRECAUTIONS/SPECIAL INSTRUCTIONS: <____> [ ] Patient is diabetic. Handout "Instructions for Patients with Diabetes having Outpatient Procedures/Tests" provided [ ] Insulin (or Insulin and Pills) [ ] Pills only [ ] [ ] per [ ] [ ] [ ] Patient is on Coumadin Patient is to hold medication for <___> days without bridging Ordering P rovider. Patient to be bridged to Lovenox injections REFERRED TO RN. Name of RN: <____> Patient to follow up with Anticoagulation Clinic or <____>
[ ] Patient is on Anti -platelet drugs: Aggrenox (aspirin plus dipryridamole), Aggrastat (tero fiban) Plavix(clopidogrel), Persantine(dipyridamole) Integrillin (eptifibatide), Ticlid (ticlopidine) ReoPro (abciximab) [ ] Patient advised to hold one week prior to procedure [ ] Aspirin or NSAIDs [ ] Patient advised to hold one week prior to proce dure Instructions: Handouts given (specify): UM Liver Biopsy (last updated June 2007) Patient Informed of: [ ] Reason for test. [ ] Diet and medication restrictions prior to test Light or Liquid breakfast the morning of procedure [ ] Need for driv er due to restrictions [ ] No driving for 12 hours post procedure
[ ] Need for activity restrictions No lifting more than 10 pounds for seven days No travel/flying for seven days [ ] Patient able to state reason for test, diet and medication restrictions, driving restrictions, activity restrictions. [ ] Patient given the opportunity to ask questions in clinic and/or number to call nurse. Patient advised to call with any questions or concerns. Related URL or References:
Methacholine Challenge Test - Patient Instructions, Vr. 2.0

Creation Date: 04/19/06 Created By: Sheila Kato Approved Date: 04/19/06 Approved By: T. Niu Revised Date: 6/5/08
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METHACHOLINE CHALLENGE TEST - PATIENT INSTRUCTIONS, Vr. 2.0 Blood Pressure (BP): <____MostRecentBloodPressure ____> PATIENT INSTRUCTION PLAN: Instruct the patient in preparation for Methacholinine Challenge Test INSTRUCTION DONE: [ ] By Phone [ ] Face to face [ ] Patient [ ] Spouse/ Significant Other [ ] Others (specify): <____> NOTE: This test cannot be perfo rmed on patients if the following conditions exist: [ ] Currently receiving Beta -Blocker agents [ ] Systolic BP > 200 or diastolic BP > 100 [ ] Pregnant / Nursing mothers [ ] Known aortic aneurysm heart attack or stroke in last 3 months [ ] Respiratory inf ection in the past 4 weeks (Does not include sinus infections) [ ] Currently using Cholinesterase inhibitor (for Myasthenia Gravis) [ ] No contraindications PATIENT HAS BEEN INS TRUCTED: [ ] Not eat/drink any food that contains caffeine for 6 hours before test
[ ] Avoid exercise and cold air for 2 hours prior to testing [ ] Avoid smoking and second hand smoke for 6 hours prior to testing THESE MEDICATIONS MU ST BE HELDFOR 48 HOU RS PRIOR TO TEST : [ ] Oral, inhaled or injected bronchodilators [ ] Oral methylxanthines (Theophylline) [ ] Corticosteroids, oral or inhaled [ ] Leukotriene modifiers [ ] Cromolyn Sodium (Intal) [ ] Tilade (Nedocromil) [ ] Primatine Mist [ ] Any prep containing Ephedrine THESE MEDICATIONS MU ST BE HELD FOR 72 HO URS PRIOR TO TE ST: [ ] Hydroxyzine [ ] Vistaril [ ] Atarax [ ] Marax [ ] Zyrtec [ ] Cetirizine THIS MEDICATION MUST BE HELD FOR 1 WEEK PRIOR TO TEST: [ ] Tiotropium (long acting Atrovent) INSTRUCTIONS: [ ] Patient/Family restates instructions and agrees to plan. [ ] Instructed About Resources or Number To Call With Ongoing Questions [ ] Written information given to patient [ ] Written information mailed to patient Related URL or References:
Test Prep - Patient Instructions, Vr. 3.0

Creation Date: 4/29/05 Created By: C. Laughlin L. Sylvest Approved Date: 4/29/09 Approved By: M. Kiss K. Ford Revised Date: 6/5/08 4/24/09
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Revised By: D. Brown C. Davies D. Brown
TEST PREP - PATIENT INSTRUCTIONS, Vr. 3.0 Allergies: <____AllergiesNoReactions____> Test Preparation Instructions: <____> Ordering Provider: <____> Scheduled Test(s) : <____> Date Test Scheduled: <____>
(FOR LIVER BIOPSY, USE LIVER BIOPSY PATIENT PREP INSTRUCTION NOTE) PRECAUTIONS/SPECIAL INSTRUCTIONS: [ ] Patient is diabetic. Handout "Instructions for Patients with Diabetes having Outpatient Procedures/Tests" provided [ ] Insulin (or Insulin and Pills) [ ] Pills only [ ] If patient is on any Metformin containing oral agent (Glucophage, Glucovance, etc), and is having a CT or test with contrast, the Metformin contai ning oral agent must be held for 48 hours after test, and the patient should have BUN/Creatinine checked before restarting med. [ ] Patient is on Coumadin [ ] Patient is to hold medication for <____> days without bridging. [ ] Patient to be bridged to Lovenox injections [ ] REFERRED TO RN: Name of RN: <____> [ ] Patient to follow up with Anticoagulation Clinic or <____> [ ] Patient is on Anti -platelet drugs: Aggrenox (aspirin plus dipryridamole), Aggrastat, (terofiban) Plavix(clopidogrel), Persa ntine(dipyridamole) Integrillin (eptifibatide), Ticlid (ticlopidine) ReoPro (abciximab) [ ] Patient advised to hold one week prior to procedure [ ] Patient is allergic to radiographic contrast or iodine [ ]For CT, MRI, Angiography, steroid prep given [ ]For ERCP, have schedulers note in comments [ ] Patient has a history of kidney disease. Check with provider if prep involves magnesium citrate or phospho soda laxative. Instructions: [ ] Handouts given (specify): <____> Patient informed of: <__ __> [ ] Reason for test(s): <____> [ ] Prep medications needed and where to obtain [ ] Diet and medication restrictions prior to test [ ] Need for driver for procedures using sedation [ ] Need for day off work or activity restrictions [ ] Written instr uctions and/or prescription given for colon prep: [ ] Nulytely [ ] One Day Prep [ ] Halflytely [ ] Two Day Prep [ ] MoviPrep [ ] Polyethylene Glycol 3350 [ ] Osmoprep
[ ] Other <____> [ ] Special Instructions (specify): <____> [ ] Patient able to sta te reason for test, prep medication usage, need for driver, need for activity restrictions and agrees with plan. [ ] Patient was given the opportunity to ask questions in clinic and/or number to call nurse. Patient advised to call with any questions or concerns. Related URL or References:
Sildenafil Citrate (Viagra) - Patient Instructions,Vr. 2.0

Creation Date:
07/07
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Created By:
A. R. Liechty, LPN
Approved Date:
12/07
Approved By:
H. Rodriguez
Revised Date:
6/5/08
SILDENAFIL CITRATE (VIAGRA) PATIENT INSTRUCTIONS ,Vr. 2.0 LEARNERS PARTICIPATING TODAY [ ] Patient [ ] Spouse/ Significant Other [ ] Others (specify): <____> Blood Pressure: <____ MostRecentBloodPressure____> PATIENT EDUCATION PLAN: Patient will receive instruction on safe use of Viagra. [ ] MEDICATION NAME: Viagra/ Sildenafil Citrate DOSE: <____> ROUTE: Oral FREQUENCY: As needed no more than once daily DIRECTIONS: As directed p er Provider [ ] INDICATION FOR MEDICATION: Erectile Dysfunction; Difficulty having an erection [ ] SPECIAL INSTRUCTIONS: Take 60 minutes before having sex Do not use more than once a day. [ ] PRECAUTIONS: Do not take with Nitrates such as Nitroglyce rin
[ ] COMMON SIDE EFFECTS May experience headache Bluish discoloration to vision is common Stuffy nose Weakness Upset stomach nausea diarrhea or indigestion Warmth or redness in your face, neck, arms, or upper chest [ ] WHEN TO CALL THE PROVIDER OR N URSE Call right away for: Priapism (erections lasting over 4 hours) Feeling lightheaded, dizziness or faint Also: Call Clinic if decrease in efficacy. Vision loss - Bluish discoloration is common. Not an indication to call the doctor or nurse. [ ] Patient verbalizes understanding and agrees with plan. [ ] Instructed about resources or number to call with ongoing questions changes.
Related URL or References:
Testing Instructions Pre-Transplant Patient Instructions, Vr. 3.0

Creation Date: 4/30/07 Created By: L. Carver Approved Date: 4/30/07 Approved By: D. Kowalczyk Revised Date: 6/5/08
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TESTING INSTRUCTIONS PRE-TRANSPLANT PATIENT INSTUCTIONS, Vr. 3.0 Dear <____>, Please remember to HOLD your <____> for 3 days prior to your Dobutamine Echo heart study. This is very important as this medication slows your heart rate while the medicine you will be given as part of the "stress" on your heart, speeds your heart rate. You should have nothing to eat or drink 4 hours prior to this study. You may resume your <____> the day after your study. If a University of Michigan scheduler or local cardiac testing office informs you there are no restrictions regarding
medications, that information is incorrect. For our purposes, evaluating you for Live r Transplantation, we require that you STOP your <____> for 3 days (72 hours) prior to this test. We have provided a description of the test for you as well. We appreciate your intention to comply with these instructions. If you have any questions feel f ree to call <____> at 1 -800-395-6431 #3, #4. Sincerely, <____> Related URL or References:
NURSING NOTES
Allergen Immunotherapy Systemic Reaction Nurse Visit Note, Vr. 5.0

Creation Date:
10/27/08
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Created By:
C. Argiero
Approved Date:
10/27/08
Approved By:
D. Kowalczyk E. Reynolds (Legal), S. Anderson (RskMgt), T. Jackson (HIM)
Revised Date:
6/5/08 02/11/2011
Revised By:
D. Brown C. Davies T. Jackson
ALLERGEN IMMUNOTHERAPY SYSTEMIC REACTION NURSE VISIT NOTE, Vr.5.0 NOTE: A copy of this form must be completed and submitted to prescribing allergy physician for each SYSTEMIC REACTION TO IMMUNOTHERAPY by the nurse administering the immunotherapy. This form must be reviewed by the allergist prescribing immunotherapy within 10 days from the event. Date of Systemic Reaction to allergen immunotherapy: <____> Date patient began allergen immunotherapy: <____> Extract contents: <____> Dosage(s): <____> Time from injection to onset of symptoms: <____> Number of previous syste mic reactions: <____> Number of previous local reactions: <____> PRE REACTION VITAL SIGNS: Blood Pressure <____MostRecentBloodPressure____> Pulse <____MostRecentPulse____> Respiratory Rate <____MostRecentRespiration____> PEFR <____> REACTION DESCRIPTION Manifestation of Reaction (include systemic and local): <____> NURSING IMPRESSION: ALLERGEN IMMUNOTHERAPY SYSTEMIC REACTION THERAPY: <____> [ ] Benadryl <____> mg route <____> [ ] Epinephrine <____> mg IM [ ] Other (specify): <____> VITAL SIGNS DURIN G REACTION: Blood pressure <____> Pulse <____> Respiratory rate <____> PEFR<____> Additional vital signs may be found in Continuity. ADDITIONAL FACTORS [ ] Exercise within 4 hours [ ] ETOH [ ] History of allergies/asthma [ ] Other health status/varia bles (specify): [ ] Recent change in medications (specify): [ ] Beta Blocker use [ ] ACE I / ARB use [ ] Current infection/antibiotics [ ] Major recent allergen exposure (specify): [ ] Injection given during seasonal allergy exposure
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Recent symp toms increase Pregnant; Last Menstrual Period (LMP) Interval since last food Use of Antihistamines in the past 24 hours Inconsistent use of Antihistamines before/on shot days New extract formulation in past 1 year New extract (specify adjustment made if any) Dosage increased today Other (specify):
PROBABLE ETIOLOGY OF SYSTEMIC REACTION: <____> Discharge Vital Signs: Blood pressure <____> Pulse <____> Respiratory rate <____> PEFR<____> DISPOSITION [ ] Discharged to home with instruction [ ] Discharged to Emergency Room [ ] Hospitalized [ ] Died [ ] Other (specify): RECOMMENDATION FOR FUTURE: [ ] Discontinue allergen immunotherapy [ ] Continue allergen immunotherapy without modification [ ] Continue allerg en immunotherapy with modifications Related URL or References:
Adult Blood Pressure Check, Vr. 2.0

Creation Date:
4/29/2005
Back to Top Revised Date: 6/5/08 Revised By: D. Brown C. Davies
Created By:
C. Laughlin
Approved Date:
4/29/2005
Approved By:
M. Kiss K. Ford
ADULT BLOOD PRESSURE (BP) CHECK, Vr. 2.0 Patient returns today for Blood pressure (BP) check per order of <____> Diagnosis: Elevated blood pressure Medications: <____> BP: <____MostRecentBloodPressure____> Pulse: <____MostRecentPulse____> Arm [ ] Right [ ] Left Size of cuff: <____> DISPOSITION: [ ] The patients blood pressure is above 160/100 or below 100/60 and on no medication. Second measurement was taken (recorded above). A provider was asked to review today. [ ] The patients blood pressure is above 160/100 or below 100/60 and on medication. Second measurement was taken (recorded above). An appointment with a provider was scheduled in 2 3 days:
[ ] The patients BP is above 200/120. The nurse or provider was consulted immediately. [ ] The patients BP is in the desired range. The patient was informed and advised to continue current regimen, and scheduled to return for any additionally prescribed blo od pressure checks and/or provider visit for ongoing management Name/Title: <____> Related URL or References:
Chemotherapy Infusion Nursing Note, Vr. 2.0

Creation Date: 06/09/06 Created By: S. Gillesse Approved Date: 06/09/06 Approved By: T. Niu Revised Date: 6/5/08
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CHEMOTHERPAY INFUSION NURSING NOTE, Vr. 2.0 VITAL SIGNS: See Care Web -CONTINUITY <____MostRecentBloodPressures____> <____MostRecentTemperature(e)____> <____MostRecentHeight(e)____> <____MostRecentWeight(e)____> ALLERGIES: Reviewed and as documented in the Problem Summary List <____AllergiesWithReactions____> ASSESSMENT: <___> SUBJECTIVE: <____> HOLD parameters reviewed and within acceptable limits INTERVENTIONS DURING ENCOUNTER: <____>A time-out was completed verifying correct patient, procedure and site for IV placement. INTRAVENOUS ACCESS (specify): [ ] Left arm [ ] Right arm PRE-MEDICATIONS : <____> OTHER MEDICATIONS : <____> CHEMOTHERAPY GIVE N (Drug, dose ):<____> [ ] NO ADVERSE REACTIONS NOTED. [ ] PATIENT HAD FOLLOWING REACTION: [ ] IV discontinued. PLAN: <____> Patient has return appointment scheduled. Other (specify): PATIENT INSTRUCTION: Reinforced post infusion instruction as per P atient Education Note.
Patient states appropriate management of side effect Patient advised to Call Provider with Questions, Concerns, or Change in Symptoms. Related URL or References:
Chronic Pain Management Nurse Visit Note, Vr. 2.0

Created Approved Approved By: Date: By: S. Jones 4/30/07 D. Kowalczyk P. Lindsey-Carr CHRONIC PAIN MANAGEMENT NURSE VISIT NOTE, Vr. 2.0 Creation Date: 4/30/07 Revised Date: 6/5/08
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REASON FOR NURSING ENCOUNTER: Monthly controlled substance contract nursing visit. ASSESSMENT: Per Pain assessment Questionnaire: On a scale of 1 -10 (0 = NO Pain and 10 = worst imaginable pain) Pain level at its worst: <____> Pain level at its best: <____> Pain level most of the time: <____> [ ] Patient is able to perform activities of daily living [ ] Pain level interferes with patients work responsibilities [ ] Yes [ ] No Patient is able to perform activities of daily living [ ] Yes [ ] No Pain level interferes with patients work responsibilities: <____> DEPRESSION ASSESSMENT QUESTIONS: [ ] Patient has little interest in activities [ ] Patient has felt sad, miserable, or hopeless during the past few weeks NURSING IMPRESSION: Chronic Pain PLAN: <____> Prescription/s given today: <____> Other (specify): <____> DISPOSITION OF CARE AT DISCHARGE FROM VIS IT: [ ] Advice per protocol (specify): <____> [ ] Appointment advised [ ] Appointment made - date: <____> [ ] Emergency Room advised - facility: <____> [ ] Provider consulted, recommendations: <____> [ ] Patient advised to call with questions, concerns, o r change in symptoms [ ] Patient to call for earlier appointment with physician if status changes. [ ] Provider follow -up action requested [ ] Contact patient [ ] Other (specify): <____>
Depo-Provera Nursing Note, Vr. 2.0

Creation Date: 09/06 Created By: S. Jones Approved Date: 09/06 Approved By: T. Niu Revised Date: 6/5/08
DEPO-PROVERA NURSING NOTE, Vr. 2.0 <____MostRecentWeight(e)____> <____MostRecentBloodPressureInDays____> Date of provider order: <____> Date of first Depo -Provera injection: <____> Date of most recent injection: <____> Date of last Pap smear: <____> Any serious medical problems since last Depo Provera? [ ] No [ ] Yes; (If yes explain): <____> Describe bleeding since last injection: [ ] No menstruation [ ] Intermittent spotting [ ] Continuous spotting [ ] Regular menses [ ] Irregular bleeding [ ] Irregular heavy bleeding [ ] Heavy and continuous bleeding [ ] Other (specify): Bleeding pattern tolerable: [] Yes [] No; (If no explain): Reported side effects: <____> Side effects tolerable: [ ] Yes [ ] No; (If no explain): NURSING IMPRESSION: <____> Medication: [ ] DEPO-PROVERA 150 MG IM GIVEN AND RECORDED IN PSL Location given: <____> Lot#:<____> Exp date: <____> Next injection due: <____> [ ] Patient stated that prolonged use of Depo -Provera may result in loss of bone density, as stated in patient information brochure. Related URL or References:
Depo-Provera, Vr. 2.0

Creation Date:
4/29/2005
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M. Kiss K. Ford
Created By:
C. Laughlin
Approved Date:
4/29/2005
Revised Date: 6/5/08
DEPO-PROVERA, Vr. 2.0
Weight: <____MostRecentWeight(e)____> Blood pressure (BP): <____MostRecentBloodPressure____> Date of provider order: <____> Date of first Depo-Provera injection: <____> Date of most recent injection: <____> Date of last Pap smear: <____> Refer to RN or Provider if any Yes responses: [ ] Depo-Provera order > one year old [ ] Pap smear on chart > one year old [ ] Is this first Depo -Provera injection [ ] Interval since last injection <11 Weeks or > 13 Weeks [ ] Wt gain >8 lbs. since last injection or >10 lbs over last year [ ] Diastolic BP>10 mm Hg above B/P at last injection patient has complaints of: Refer to RN or Provider if any Yes responses: [ ] sharp chest pain, sudden SOB or hemoptysis [ ] sudden severe headache, vomiting, fainting or dizziness [ ] visual changes [ ] difficulty with speech [ ] extremity weakness or numbness [ ] severe pain or swelling in the calf [ ] unusually heavy bleeding [ ] severe pain or tenderness in lower abdominal area [ ] persistent pain, pus or bleeding at the injection site [ ] Other (specify): Describe bleeding since last injection: [ ] No menstruation [ ] Intermittent spotting [ ] Conti nuous spotting [] Regular menses [ ] Irregular bleeding [ ] Irregular heavy bleeding [ ] Heavy and continuous bleeding [ ] Other (specify): Bleeding pattern Patient reports bleeding pattern is tolerable. [ ] Yes [ ] No; (If no refer to RN or provider ) Reported side effects: Patient reports Side effects are tolerable [ ] Yes [ ] No; (If no refer to RN or provider) Medication: [ ] DEPO-PROVERA 150 MG IM GIVEN AND RECORDED IN PSL Location given: <____> Lot#: <____> Exp date: <____> Next injection due: <____> [ ] Patient given appointment information. [ ] Patient stated that prolonged use of Depo -Provera may result in loss of bone density, as stated in patient information brochure. Name/Title: <____> Related URL or
References:
Dermatology Treatment Discharge Care Plan Nursing Note, Vr. 1.0

Creation Date:
4/10/09
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Created By:
J. Witten
Approved Date:
4/27/09 No response
Approved By:
HIM Billing
Revised Date:
Revised By:
DERMATOLOGY TREATMENT DISCHARGE CARE PLAN NURSING NOTE, Vr. 1.0 Subjective: <____> Objective: Treated at the Dermatology TaubmanCenter for <____> days with Modified Goeckerman therapy. [ ] At discharge, skin integrity presents with decreased erythema. [ ] Plaques have decreased area of thickness [ ] Other: <____> Assessment: [ ] Patient outcome of skin improvement achieved [ ]Patient outcome of skin improvement not achieved [ ]Other: <____> Plan: [ ] Return visit scheduled: Date <____> [ ] See Ambulatory Phototherapy Treatment Center sheet for discharge orders PATIENT INSTRUCTION Written home care instructions included in Patient Handbook and reviewed with patient. Reviewed rationale for homecare plan and stress importance of compliance with plan for optimum results. Questions answered. [ ] Patient/Family restates instructions and agrees wi th plan. [ ] Instructed About Resources and Number To Call With Ongoing Question(s). Related URL or References:
Dermatology Treatment Nursing Assessment, Vr. 1.0

Approved By: HIM No response Billing DERMATOLOGY TREATMENT NURSING ASSESSMENT, Vr. 1.0 ADMITTED FROM: <____> MEDICAL DIAGNOSIS/Chief Complaint: <____> Reason for Admission/ Transfer: <____> CHIEF COMPLAINT Duration: <____> Previous Admissions: <____> Creation Date: 4/10/09 Created By: Jeanine Witten Approved Date: 4/27/09 Revised Date:
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Previous Treatments: <____> Treatments during Past Month: <____> Other Medical Problems/ Conditions: <____> CURRENT MEDICATIONS: <____ActiveMedsNoDate____> VITAL SIGNS: Blood Pressure: <____24hourBloodPressure____> Pulse: <____24hourPulse____> Temperature: <____24hourTemperature(E)____> PATIENTS EXPECTATIONS DURING ADMISSION: <____> ANY LIMITATIONS OF ADMISSION: <____> LAST OUTPATIENT CLINIC VISIT: Date: <____> Location: <____> Physician: <____> HEALTH HISTORY REVI EW OF SYSTEMS CIRCULATORY : [ ] Hypertension [ ] Chest Pain [ ] Palpitations [ ] Syncope [ ] Edema [ ] Other: <____> RESPIRATORY: [ ]SOB [ ]Cough [ ]Sputum [ ]Smoking History [ ]Other (specify): <____> MOTOR: [ ]Stiff Joints [ ]Weakness [ ]Other: <_ ___> NEUROLOGIC: [ ]Headache [ ]Seizure [ ]Tremor [ ]Other: <____> UROLOGIC: [ ] Infection/Discharge [ ] Genital Sores [ ] Dysuria [ ] Urinary Frequency [ ] Other: <____> GASTROINTESTINAL: [ ] Constipation [ ] Diarrhea [ ] Nausea [ ] Vomiting [ ] Ora l Sores [ ] Heartburn [ ] Weight Gain <____>lbs [ ] Weight Loss <____>lbs [ ] Other: <____> ENDOCRINE: [ ] Diabetes [ ] Other: <____>
SPECIAL SENSES: [ ] Alterations in Vision [ ] Hearing [ ] Taste [ ] Smell [ ] Other: <____> REST AND COMFORT: [ ] Pain Describe: <____> Pain Scale: <____>/10 [ ] Usual/Sleep Pattern <____>Hrs/Night [ ] Sleep Dysfunction [ ] Sleep Aid: <____> [ ] Other: <____> MENTAL/ EMOTIONAL: General Appearance during Interview: [ ]Cooperative [ ]Angry [ ]Depressed [ ]Anxious [ ]Other: <____> STRESS FACTORS: Recent Changes at: [ ]Home [ ]Work [ ]School [ ]Other: <____> Coping Mechanisms: <____> SKIN: General Appearance: <____> [ ] Fissures [ ] Exfoliation [ ] Excoriations [ ] Erythema: [ ] Excessive [ ] Moderate [ ] Minimal [ ] Pruritus: [ ] Severe [ ] Moderate [ ] Minimal [ ] Nail Disorder: [ ] Thickened [ ] Pitted [ ] Other: <____> [ ] Scalp Disorder:[ ] Scalp Lesions [ ] Ear Lesions [ ]Scales [ ] Erythema [ ] Other: <____> [ ]Facial Involvement: [ ] Erythema [ ] Scales [ ] Other: <____> NURSING IMPRESSION: <____> DISPOSITION OF CARE:<____> PATIENT INSTURCTIONS: [ ] Oriented to Dermatology TaubmanCenter and Protocols Related URL or References:
Diagnostic Testing (Pediatric Infusion) Nursing Note, Vr 1.0

Creation Created Approved Approved Revised Date: By: Date: By: Date: 2/28/06 M. Wlodyga 3/2/06 Tori Niu DIAGNOSIC TESTING (P EDIATRIC INFUSION) N URSING NOTE VR 1.0 TEST NAME :<____>
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Revised By:
ASSESSMENT: <____> SUBJECTIVE: Patient is adequately prepared prior to diagnostic testing to ensure successful test Yes< ____>No OBJECTIVE: Weight:<____MostRecentWeight(e)____> Height: <____MostRecentHeight(e)____> Allergies: <____AllergiesWithReactions____> Describe: <____> INTERVENTIONS DURING ENCOUNTER: <____>A time-out was completed verifying correct patient, procedure, site, positioning, and implant(s) or special equipment. [ ] Heplock placed: [ ] Venipuncture: [ ] Patient tolerated the access procedure age appropriate [] Labs obtained per test protocol. [ ] Other (Specify): PRESUMED DIAGNOSIS: <____> OUTCOME: [ ] Completed test [ ] Reschedule testing DISPOSITION OF CARE AT DISCHARGE FROM VISIT: [ ] PROVIDER CONSULTED, RECOMMENDATIONS: PATIENT EDUCATION: [ ] Test protocol reviewed w/parent and patient. [ ] Expect test results within 2 weeks after testing. [ ] Expect follow -up per Provider following test result. [ ] Verbalized understanding [] Yes [] No [ ] Patient/Parent advised to call Provider with questions, concerns, or change in symptoms. [ ] Other (specify): Related URL or References:
Dressing Change, Vr. 2.0

Creation Date:
4/29/2005

M. Kiss K. Ford
Created By:
C. Laughlin
Approved Date:
4/29/2005
DRESSING CHANGE, Vr. 2.0 This patient returns today to have dressing changed per order of <____>. RN/Provider notified if patient reports: [ ] Worsening or no improvement of wound. [ ] Continued or worsening pain at wound site. [ ] Thick, purulent or bloody drainage [ ] Fever. If yes, temperature today: Other (specify):
OBSERVATIONS AND CARE: Wound location: <____> Appearance of wound: <____> Drainage color and amount: <____> Cleaned/irrigated with: <____> Technique: [ ] clean [ ] sterile Type of dressing applied: <____> Patient tolerated the procedure well. Signs and symptoms of infection reviewe d per patient education materials and patient instructed to call clinic if noted. Name/Title: <____> Related URL or References:
Ear Irrigation, Vr. 2.0

Creation Date:
4/29/2005

M. Kiss K. Ford
Created By:
C. Laughlin
Approved Date:
4/29/2005
EAR IRRIGATION, Vr. 2.0 Patient returns today to have ear irrigation per order of <____> [ ] Right [ ] Left Ear [ ] Both Solution Used: [ ] Tepid water [ ] Hydrogen Peroxide and tepid water [ ] Other (specify): [ ] Ear Wax Softener Used (specify): <____> Results of Procedure: <____> Amount of Return: <____> Color of Cerumen: <____> Patient Tolerated Procedure: [ ] No problems [ ] Patient complains of d izziness or pain. Procedure stopped. <____> [ ] Provider notified [ ] RN notified [ ] Other (specify): NAME/TITLE: <____> Related URL or References:
Epinephrine Auto Injector- Patient Instruction, Vr.1.0

Creation Date: Created By: Approved Date: Approved By: Revised Date:
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Revised By:
4/17/08 T. Thielan 34/17/08 D. Kowalczyk EPINEPHRINE AUTO -INJECTOR - PATIENT INSTRUCTION, Vr.1.0 LEARNERS PARTICIPATING TODAY [ ] Patient [ ] Parent/Caregiver [ ] Others (specify): MEDICATION: [ ] EpiPen [ ] Twinject PATIENT INSTRUCTION PLAN: Instruct patient epinephrine auto -injector dose/technique, causes of anaphylaxis, indications for use, how to store/dispose of and return demonstration. INSTRUCTIONAL INTERVENTIONS IMPLEMENTED TODAY: Patient Instructed on the following: MEDICATION: [ ] EpiPen [ ] Twinject [ ] Dose: 0.15mg or 0.3mg as ordered Immediately call 911 or seek emergency treatment as indicated May repeat dose in ten minutes if no relief or symptoms return After dose has been given from EpiPen, e xtra medication will remain in syringe that cant be used Additional dose of medication is contained in a syringe within the Twinject after initial injection. Directions are on Twinject injector if second dose of epinephrine is needed. Auto-injector should remain in close proximity in case of need at any given time INDICATION: Allergic reaction of anaphylaxis due to: [ ] Bite or sting from insect [ ] Foods [ ] Medications [ ] Latex [ ] Unknown [ ] Other: <____> [ ] REVIEW OF SYMPTOMS S IGNS AND SYMPTOMS REQUIRIN G USE OF EPINEPHRINE AUTO -INJECTOR: This is for emergency supportive therapy only and is not a replacement or substitute for immediate medical care. Tingling or warm sensation Itching, hives Metallic taste or swelling of the mouth and throat Wheezing, coughing, difficulty breathing Vomiting, diarrhea, or cramping Loss of consciousness [ ] PROPER INJECTION TECHNIQUE Remove auto -injector from hard plastic case and remove safety cap(s) With dominant hand, grasp injector and inj ect through clothing (if necessary), into large thigh muscle Hold for count of ten, auto -injector is spring loaded Massage area for ten seconds If second dose is necessary, follow directions imprinted on
the Twinject auto -injector. EpiPen auto -injectors are single dosed and therefore, should remain together as dispensed. [ ] STORAGE AND DISPOSAL OF AUTO -INJECTORS Protect from light, store at room temperature, protect from freezing, do not refrigerate Observe expiration dates or discolored fluid in injector, replace as necessary Dispose of in approved sharps collector [ ] COMMON SIDE EFFECTS: Anxiety, apprehensiveness, restlessness Weakness, tremor, dizziness, headache, sweating Irregular heartbeat, nausea, vomiting, breathing difficulty [ ] WRITTEN MATERIAL, DV D, AUTO-INJECTOR TRAINER GIV EN/REVIEWED WITH PATIENT [ ] Patient able to state Indication for Medication, Signs and Symptoms requiring usage, storage and disposal and common side effects. [ ] Patient demonstrated proper Injecti on Technique DISPOSITION [ ] Re-Instruct [ ] Review [ ] Refer to Ordering Provider with further questions [ ] Instructed about resources or number to call with ongoing questions Related URL or References:
Headache Assessment Pediatric Neurology Nursing Note, Vr. 2.0

Creation Date: 4/30/07 Created By: H. Murrel Approved Date: 4/30/07 Approved By: D. Kowalczyk Revised Date: 6/5/08
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HEADACHE ASSESSMENT PEDIATRIC NEUROLOGY NURSING NOTE, Vr. 2.0 ASSESSMENT: Number of headaches per day <____>, per week <____>, Per month <____> Duration of headache: <____> Minutes, <____> Hours, <____> Days [ ] Concurrent illness describe: <____>, Febrile [ ] CURRENT HEADACHE MEDICATIONS: [ ] Missed doses (When): <____> [ ] Adverse Effects(describe): <____> OTC Meds used: <___ _> DESCRIPTION OF HEADA CHE [ ] Typical headache for this child. See Care Web Note dated: <____> [ ] Missing school days <____> per week, <____> per month [ ] Need letter [ ]Mail [ ]fax <____>
DETAILS OF HEADACHE: [ ] Level of pain (0= No Pain to 10 = M ost Severe): <____> [ ] Cried [ ] Confused [ ] Blurred vision [ ] right eye [ ] left eye [ ] Numbness/tingling Arms: Right. [ ] Left [ ] Legs: Right. [ ] Left [ ] [ ] Dizziness [ ] Emesis (describe): <____> [ ] Disturbed/behavior (describe): <____> [ ] Other (specify): <____> DURING HEADACHE: [ ] Photophobia [ ] Phonophobia [ ] Area of pain <____> [ ] Possible triggers (including sleep, hygiene): <____> [ ] Other (Specify): <____> POST HEADACHE: [ ] Confusion [ ] Irritability [ ] Child returned to school [ ] Participated in school activities [ ] Other (Specify): <____> Additional information: <____> NURSING IMPRESSION: <____> PLAN: [ ] Review with physician [ ] Increase <____> medication to: <____> [ ] Decrease <____> medication to : <__ __> [ ] Start new medication: <____> [ ] Medication changes called to pharmacy <____> Phone <____> fax <____> [ ] Repeat labs (specify): <____> Repeat days [ ] weeks [ ] month [ ] not needed [ ] PATIENT EDUCATION : [ ] Drug information and dosing instruc tions: Discussed [ ] Mailed copy [ ] date [] [ ] Emergency Care and Safety Issues discussed [ ] date <____> [ ] Emergency contact after office hours given [ ] [ ] Caregiver will continue to keep log of headaches. [ ] Caregiver will call if side effects or headaches continue [ ] Caregiver verbalizes instructions and agrees to plan Related URL or References:
Hyperlipidemia Assessment for Diabetic Patients Nursing Note Or Education Note, Vr. 1.0
Creation Date: Created By: Approved Date: Approved By: Revised Date:
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Revised By:
10/7/08
Patty Lindsay-Carr Mary Sue Webb Diane Brown
10/7/08
Daniel Kowalczyk
HYPERLIPIDEMIA ASSESSMENT FOR DIABETIC PATIENTS NURSING NOTE OR EDUCATION NOTE, Vr. 1.0 LEARNERS PARTICIPATING TODAY: [ ] Patient [ ] Spouse/ Significant other [ ] Others (specify): [ ] Patient is currently taking antidyslipidemics (specify):<____> Length of time on this dose: <____> Patient is currently making lifestyle changes by: [ ] Following a low -saturated fat, low -cholesterol diet. [ ] Working on weight reduction diet (specify):<____> [ ] Patient is physically active and has a routine exercise program. Type of activity: <____> <____> minutes <____> times a week [ ] Working on increasing exercise (specify): <____> [ ] Patient has set Individual Goal(s)(specify): <____> [ ] Educated per the Lipid Screening and Management clinical care guideline www.med.umich.edu/i/oca/practiceguides [ ] Other NURSING IMPRESSI ON: [ ] Patient ready to make changes as discussed above. [ ] Other <____> EVALUATION: [ ] Knowledge Achieved [ ] Developing Knowledge [ ] No Learning Evident EVIDENCE OF LEARNING: [ ] Return Demonstration [ ] Teach -Back [ ] Other (specify): DISPOSITION: [ ] Reteach: [ ] Reinforce/More Practice/Review [ ] Referral to Another Provider Advised/Made (Describe): [ ] Other (specify): [ ] Referred to dietician [ ] Instructed About Resources or Number To Call With Ongoing Question Related URL or References:
Hypertension Assessment for Diabetic Patients Nursing Note or Education Note, Vr.
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1.0
Creation Date:
10/7/08
Created By:
Patty Lindsay-Carr Mary Sue Webb Diane Brown
Approved Date:
10/7/08
Approved By:
D. Kowalczyk
Revised Date:
Revised By:
HYPERTENSION ASSESSMENT FOR DIABETIC PATIENTS NURSING NOTE OR EDUCATION NOTE, Vr. 1.0 LEARNERS PRESENT TODAY: [ ] Patient [ ] Spouse, Significant other [ ] Others (specify): <____> [ ] Patient is on antihypertensive medication (specify): <____> Length of time on this dose: <____> [ ] Patient is able to state own blood pressure goal: <____> If No: [ ] Informed patient of documented goal of <____> [ ] Informed of goal less than 135/80 (no other documented goal) [ ] Patient monitors own blood pressure at home [ ] Yes [ ] No (Readings): <____> If No [ ] Patient is interested in learning how to take own BP at home. [ ] Instructed and describes Blood press ure monitoring and recommended equipment How to contact provider with elevated readings [ [ [ [ [ ] ] ] ] ] Patient is currently making lifestyle changes Follows a weight reduction diet (specify):<____> Monitors the amount of salt/sodium intake Discussed ways of decreasing sodium in diet Other diet (specify) : <____>
[ ] Patient is physically active and has a routine exercise program. Type of activity: <____> <____> minutes <____> times a week [ ] Working on increasing exercise (specify): <____> [ ] Patient not making Life Style changes [ ] Instructed on benefits of weight reduction, exercise, smoking cessation and healthy diet [ ] Patient has set Individual Goal(s)(specify): <____> NURSING IMPRESSION: [ ] Patient ready to make changes as discus sed above [ ] Comments: <____> EVALUATION: [ ] Knowledge Achieved [ ] Developing Knowledge [ ] No Learning Evident EVIDENCE OF LEARNING: [ ] Return Demonstration [] Teach-Back [ ] Other (specify):
DISPOSITION: [ ] Reteach: <____> [ ] Reinforce /More Practice/Review [ ] Referral to Another Provider Advised/Made (Describe): [ ] Other (specify): <____> [ ] Instructed About Resources or Number To Call With Ongoing Question Related URL or References:
Immune Globulin Intravenous (IVIG) Infusion Nursing Note, Vr. 2.0

Creation Date: 3/15/06 Created By: E. Edwards Approved Date: 3/15/06 Approved By: K Ford Revised Date: 6/5/08
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Revised By: D. Brown C. Davies IMMUNE GLOBULIN INTR AVENOUS (IVIG) INFUSION NURSING NOTE Vr. 2.0 ASSESSMENT: <____> SUBJECTIVE: <____> [ ] Denies any complications since last infusion. [ ] Other (specify):<____> OBJECTIVE: Alert and oriented to time, place and person. Skin is warm, dry and pink. Initial vital signs are: Blood Pressure (BP):<____MostRecentBloodPressure____> Pulse (P): <____M ostRecentPulse____> NURSING IMPRESSION: <____> INTERVENTIONS DURING ENCOUNTER: <____>A time-out was completed verifying correct patient, procedure, site, positioning, and implant(s) or special equipment. Premeds: <____> <____> gauge. Angio started in <____> with brisk flow of blood returned. Immune Globulin Intravenous <____>gms. Reconstituted with <____> mL normal saline. Lot Number: <____> ; Expiration date: <____> Infused over <____> hours without complications. Observed for 30 minutes post m edication infused. Normal saline 250 mL infused during observation. Final vital signs are: BP<____>, P <____> No complications noted. Further vital signs in CareWeb Continuity. IV discontinued.
[ ] Labs drawn (specify):<____> DISPOSITION OF CARE AT D ISCHARGE FROM VISIT: <____> PLAN: <____> Infusion every <____> weeks PATIENT INSTRUCTION: [ ] Reinforced post infusion instructions: Medication - Intravenous Immune Globulin: Given for problems with immune system. Helps prevent infections or make the i nfection less severe. Treats low platelets due to ITP. Possible Side Effects - Renal dysfunction and acute renal failure. Notify Physician/Nurse - immediately if symptoms of decreased urine output, sudden weight gain, fluid retention/edema, and/or shortness of breath occur. [ ] Written Medication Information given [ ] Phone numbers of physician/nurse given [ ] Patient/Family restates instructions and agrees to plan. Related URL or References:
Injection/Medication (Pediatric Infusion) Nursing Note, Vr. 2.0

Creation Date: 2/28/06 Created By: M. Wlodyga Approved Date: 3/2/06 Approved By: Tori Niu Revised Date: 6/5/08
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INJECTION/MEDICATION (PEDIATRIC INFUSION) NURSING NOTE, Vr. 2.0 REASON FOR NURSING ENCOUNTER: <____> ASSESSMENT: <____> SUBJECTIVE: <____> [ ] Side effects from previous administration of Medication: <____> OBJECTIVE: Weight: <____MostRecentWeight(e)____> Height: <____MostRecentHeight(e)____> Allergies: <____AllergiesWithReactions____> NURSING IMPRESSION: <____> INTERVENTIONS DURING ENCOUNTER: <____> A time -out was completed verifying correct patient, procedure, site, positioning, and implant(s) or special equipment. [ ] Medication/Dose: <____> [ ] Site: <____> [ ] Patient tolerated procedure in manner appropriate to age. DISPOSITION OF CAR E: <____> Next Injection due: <____>
PATIENT INSTRUCTION: [ ] Common side effects and their management reviewed with Parent/Patient [ ] Patient advised to call Provider with question, concerns, or change in symptoms. [ ] Other (specify):<____> [ ] Patient/Family restates instructions and agrees to plan. Related URL or References:
Intravenous Infusion Nursing Note, Vr. 1.0

Creation Date: 3/15/06 Created By: M. Brancheau Approved Date: 3/15/06 Approved By: K Ford Revised Date: 6/5/08
INTRAVENOUS INFUSION NURSING NOTE, Vr. 1.0 <____>A time-out was completed verifying correct patient, procedure and site for IV placement. <____> gauge angiocath started in <____>, with brisk flow of blood returned. <____> ml of <____> fluid infused over <____> hours without complications. Infusion Start Time: <____> Finish Time: <____> IV discontinued. Any IV medications given are recorded on the PSL. Vital Signs taken are documented in Continuity. DISPOSITION OF CARE: [ ] Home [ ] Hospital [ ] Other (specify): [ ] Patient advised to Call Provider with Questions, Concerns, or Change in Symptoms. Related URL or References:
Lupron Depot Nursing Note, Vr. 2.0

Created Approved By: Date: 8/17/2007 8/17/2007 Y. Small LUPRON DEPOT NURSING NOTE, Vr. 2.0 Date of provider order: <____> History: Indication for Lupron Depot: [ ] Fibroids [ ] Bleeding / Anemia [ ] Endometriosis [ ] Postpone Puberty [ ] Prostate Cancer [ ] Other (specify): <____> Creation Date: Approved By:
H. Rodriguez
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Date of most recent injection: <____> [ ] Medication brought to clinic by Patient. Vital Signs: Weight: <____MostRecentWeight(e) ____> Blood Pressure: <____MostRecentBloodPressure____> Pulse: <____Mo stRecentPulse____> ASSESSMENT : [ ] No Unusual Findings [ ] Sharp chest pain, sudden SOB or hemoptysis [ ] Sudden severe headache, vomiting, fainting or dizziness [ ] Visual changes [ ] Difficulty with speech [ ] Extremity weakness or numbness [ ] Severe pain or swelling in the calf [ ] Unusually heavy bleeding [ ] Severe pain or tenderness in lower abdominal area [ ] Persistent pain, pus or bleeding at the injection site [ ] Other (specify): <____> NURSING IMPRESSION: <____> DISPOSITION OF CARE: [ ] Lupron Depot <____> mg. Route <____> and <____> recorded in PSL Location given:<____> Lot#: <____> Exp date: <____> Next injection due: <____> [ ] Patient given appointment information. [ ] Follow -up appointment with provider <____> [ ] Patient verbali zed understanding and agrees to plan. Patient Instruction: [ ] Review of side effects and risk of Lupron Depot. (Hot flashes, uncomfortable intercourse, osteoporosis, peripheral edema, decreased libido) [ ] Patient provided with written information on Lup ron Depot [ ] From manufacturer [ ] Micromedex [ ] Patient verbalized understanding of treatment and agrees to plan. The patient was advised to call clinic if he/she had any questions, concerns or problems. He/she was given the paging operator number if questions, concerns or problems during after hours, weekend or holidays. Related URL or References:
Methotrexate Injection Nurse Visit Note, Vr. 1.0

Creation Date:
10/7/08
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Created By:
D. Czarnota
Approved Date:
10/7/08
Approved By:
D. Kowalczyk
Revised Date:
Revised By:
Methotrexate Injection Nurse Visit Note, Vr. 1.0
INTERVENTIONS DURING ENCOUNTER: Vital Signs: Weight: <____MostRecentWeight(e) ____> Blood pressure: <____MostRecentBloodPressureInDays____> Pulse: <____MostRecentPulse____> [ ] HOLD parameters reviewed and the following labs are within administration limits: [ ] BHCG [ ] CBCP [ ] Creatinine [ ] LFTs [ ] RHA [ ] A time -out was completed verifying correct patient and procedure [ ] Medicatio n double check performed by signer and <____> RN per UMHS policy. [ ] Methotrexate <____> mg administered intramuscularly using two syringes Site(s): [ ] Left gluteus maximus [ ] Right gluteus maximus [ ] Left vastuslateralis [ ] Right vastuslateralis [ ] Other <____> DISPOSITION OF CARE AT DISCHARGE FROM VISIT: [ ] Labs to be drawn on <____> and <____> [ ] Requisitions given to patient to hand carry to lab. [ ] Follow up appointment with provider given [ ] Patient advised to call with questions, conc erns or change in symptoms PATIENT INSTRUCTION [ ] Patient instruction materials on Methotrexate provided and reviewed with the patient [ ] Patient able to state reason for methotrexate administration, side effects and management, and follow up plan. Pa tient agrees with plan. Related URL or References:
Newborn Weight Check Visit Vr. 2.0

Creation Date: 4/29/2005 Created By: C. Laughlin Approved Date: 4/29/2005 Approved By: M. Kiss K. Ford Revised Date: 6/5/08
NEWBORN WEIGHT CHECK VISIT Vr. 2.0 Patient returns today for check of weight and feeding per order of <____>.
The newborn is fed [] Breast Milk [] formula, < ____> times a day, with < ____> minutes or <____> ounces at each feeding. [ ] Yes [ ] No The newborn is stooling several times a day and making at least one wet diaper every 6 hours. If no, RN or provider notified: <____> The newborn weighed <____> at bi rth and <____> at the last visit on <______>. Today the weight is <____MostRecentWeight(e)____>. [ ] Yes [ ] No The infant is pink, active and has a strong cry. IMPRESSION: Failure to gain weight DISPOSITION (Choose one): [ ] The newborn has regained b irth weight and will be seen at the 2 month well child exam. [ ] The newborn has gained 20 -30 grams/day since the last weight check but is not yet at birth weight and will be scheduled for a return visit in 4 -7 days. [ ] The newborn has not gained adequate weight and a physician was asked to see the infant today. PARENT INSTRUCTION: The parent was given instructional information in feeding the newborn from the on -line patient advisor resource: For Breast -fed newborns: How Do I Know My Baby Is Getting Eno ugh Milk? http://www.med.umich.edu/1libr/pa/pa_howdoikn_hhg.htm or For Bottle -fed newborns: Formula (Bottle) Feeding. http://www.med.umich.edu/1libr/pa/pa_formula_hhg.htm Name and title: <____> Related URL or References: Breast-fed: http://www.med.umich.edu/1libr/pa/pa_howdoikn_hhg.htm Bottle-fed: http://www.med.umich.edu/1libr/pa/pa_formula_hhg.htm
Nurse Visit Note, Vr. 2.0

Creation Date:
6/30/2004

R. Whitehouse
Created By:
C. Laughlin
Approved Date:
6/30/2004
NURSE VISIT NOTE, Vr. 2.0 REASON FOR NURSING ENCOUNTER: <____> ASSESSMENT: <____> SUBJECTIVE: <____> OBJECTIVE: <____>
NURSING IMPRESSION: <____> PLAN: <____> INTERVENTIONS DURING ENCOUNTER: <____> PATIENT EDUCATION/INSTRUCTION: <____> Patient restates plan and agrees with the plan of care. DISPOSITION OF CARE AT DISCHARGE FROM VISIT: [ ] Advice per protocol specify: <____> [ ] Appointment advised [ ] Appointment made date: <____> [ ] Emergency Room advised Facility: [ ] Provider consulted, recommendations: [ ] Patient advised to call with questions, concerns, or change in symptoms [ ] Other (specify): Provider follow -up action requested [ ] Contac t patient [ ] Advise/prescribe: ALLERGIES: <____AllergiesWithReactions____> [ ] Review and sign [ ] Other (specify): Related URL or References:
Nursing Note (Pediatric Infusion),Vr. 2.0

NURSING NOTE (PEDIATRIC INFUSION), Vr. 2.0 PRE INFUSION ASSESSMENT: SUBJECTIVE: Medication Response since last visit: <____> OBJECTIVE: Weight: <____MostRecentWeight (e)____> Height: <____MostRecentHeight(e)____> Body Surface Area (BSA) :<____> Allergies: <____AllergiesWithReactions____> DIAGNOSIS: <____> INFUSION: <____> A time -out was completed verifying correct patient, procedure, site, positioning, and implant( s) or special equipment. [ ] Heplock placed: <____> [ ] Premeds Required Premeds/dose: <____> [ ] Access Type and location: <____> Infusion Start Time: <____> Finish Time: <____>
Vital Signs: <____> Intake: <____> Output: <____> OUTCOME: [ ] Infusion Tol erated [ ] Infusion NOT tolerated (Explain): <____> [ ] Completed Infusion [ ] Infusion Not Completed (Explain): <____> [ ] Other (Specify): <____> DISPOSITION OF CARE: [ ] Next Infusion Appointment: <____> [ ] Discharge Home [ ] Discharged to Hospital [ ] Other (Specify): <____> PLAN/INTERVENTIONS: [ ] Provider Consulted, Recommendations: <____> [ ] Other specify: <____> PATIENT INSTRUCTION: [ ] Infusion protocol reviewed Family and Patient [ ] Common side effects and their management reviewed Family/Patient [ ] Monitor for side effects. [ ] Patient advised to Call Provider with Questions, Concerns, or Change in Symptoms [ ] Other (Specify):<____> [ ] Patient/Family restates instructions and agrees to plan. Related URL or References:
Pediatric Blood Pressure Check, Vr. 2.0

Creation Date:
4/29/2005
Created By:
C. Laughlin
Approved Date:
4/29/2005
Approved By:
M. Kiss K. Ford
PEDIATRIC BLOOD PRES SURE (BP) CHECK, Vr. 2.0 Patient returns today for blood pressure (BP) check per order of <____> Diagnosis: Elevated blood pressure The patients BP was measured today using [ ] Manual [ ] Electronic A <_____> size cuff was used on the patients [ ] Left [ ] Right [ ] Arm [ ] Leg BP: <____MostRecentBloodPressure____> P: <____MostRecentPulse____> A <_____> size cuff was used on the patients [ ] Left [ ] Right [ ] Arm [ ] Leg DISPOSITION: [ ] The patients blood pressure was normal for age today and this will be reported to the requesting physician. [ ] The patients blood pressure was > 95% for age and a
physician was asked to review today. Name/Title: <____> Related URL or References:
Procedure (Pediatric Infusion) Nursing Note, Vr 2.0

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PROCEDURE (PEDIATRIC INFUSION) NURSING NOTE, Vr. 2.0 PROCEDURE: <____> ASSESSMENT SUBJECTIVE: <____> OBJECTIVE: <____> Weight: <____MostRecentWeight(e)____> Height: <____ MostRecentHeight(e)____> ALLERGIES: <____AllergiesWithReactions____> INTERVENTIONS TODAY: <____> A time -out was completed verifying correct patient, procedure, site, positioning, and implant(s) or special equipment. OUTCOME: [ ] Procedure completed [ ] YES [ ] NO If no, explain: <____> [ ] Patient tolerated Procedure age appropriate [ ] Other (specify) : <____> PATIENT/FAMILY INSTRUCTION: [ ] Procedure explained to Family and Patient [ ] Post Procedure Instructions given to patient /family. [ ] Patien t/Family restates instructions and agrees to plan. DISPOSITION OF CARE: [ ] Provider consulted, recommendations: [ ] Patient advised to call provider with questions, concerns, or change in symptoms. [ ] Other (specify):<____> Related URL or References:
Remicade Infusion Nursing Note, Vr. 3.0

Creation Date:
11/7/08
Created By:
E. Edwardst
Approved Date:
11/17/08
Approved By:
D. Kowalczykz
Revised Date:
6/5/08
REMICADE INFUSION NURSING NOTE, Vr. 3.0 REASON FOR NURSING ENCOUNTER: Remicade infusion. ASSESSMENT: <____> SUBJECTIVE: <____> OBJECTIVE: Alert and oriented to time, place and person. Skin is warm, dry and pink. NURSING IMPRESSION: <____> PLAN: Remicade infusion every <____> weeks per order of <____> INTERVENTIONS DURING ENCOUNTER: Premeds: Initial vi tal signs: Blood pressure <____MostRecentBloodPressure____>, Pulse <____MostRecentPulse____> <____> gauge angio started in <____> with brisk flow of blood returned. Remicade<____> mg in 250 mL normal saline infused over 2 hours. LOT #: <____> Expiration date: <____> Observed for 30 minutes post Remicade infusion. 250 mL normal saline flush infused during observation. Final vital signs are: <____>. Additional vital signs in continuity. Total volume infused: <____> [ ] Complications noted (specify):<____ > [ ] Labs drawn [ ] Instructed About Resources or Number To Call With Ongoing Question. Related URL or References: Remicade (Infliximab) Current Prescribing Information, Comprehensive Nursing Approach to Infliiximab Infusion Therapy,Journal of Infusion Nursing, vol. 26, Nov./Dec. 2003 Back to Top
Scheduling Request to East Ann Arbor Infusion Center, Vr. 2.0

Created By / Date:
M. Cano 11/2010
Approved By / Date
T. Jackson (HIM)/ 12/2010 M. Cano/ 12/2010
Revised By / Date:
T. Jackson (HIM) M. Cano/ 06/2011
Recommended Doc Type
SCHEDULING REQUEST TO EAST ANN ARBOR INFUSION CENTER, Vr. 2.0 Date: <____> Main Diagnosis: <____> ICD-9 Code: <____> Ordering Provider Name: <____> Provider Number and/or Pager Number: <____>: Backup Provider Coverage: (Physician to contact if ordering provider is unavailable): Name: <____>, Provider Number: <____> Backup Coverage for GI: Ordering physician. If not available, page <____> . If not available, then page GI consult fellow. Backup Coverage for Rheumatology: Ordering physician then
Rheumatology fellow on -call. Medication Ordered:<____> Dose(s) :<____> Frequency: <____> Has the patient ever received this medication before? [ ] No [ ] Yes If Yes, did patient experience any reaction? [ ] No [ ] Yes If Yes, was the reaction: [ ] Mild [ ] Moderate [ ] Severe Is a Port or PICC Line Present? [ ] No [ ] Yes Mobility: [ ] Ambulatory [ ] Wheelchair Bound [ ] Stretcher Bound If a patient has a physical or mental impairment, confirm a caregiver will accompany the patient? [ ] Confirmed Specify date and caregiver name: <____> Will lift equipment be needed to assist patient in transferring? [ ] No [ ] Yes Does the patient reside i n a care facility or require supervision? [ ] No [ ] Yes Does the patient use supplemental oxygen? [ ] No [ ] Yes Does the patient require any contact precautions? [ ] No [ ] Yes If the patient requires an interpreter, indicate language : <____> Additional Medical Conditions not addressed above : <____> Related URL or References:
Sore Throat and Positive Strep Protocol Adult Nursing Note, Vr. 1.0
Creation Date: 3/30/09 Created By: Pam Szymanski
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Approved Approved Revised Date: By: Date: 4/22/09 B. Myers HIM 4/23/09 Pro Fee SORE THROAT AND POSI TIVE STREP PROTOCOL ADULT NURSING NOTE, Vr 1.0 ASSESSMENT [ ] Positive strep culture [ ] sore throat [ ] fever [ ] swollen glands
Revised By:
[ ] Recent exposure to strep: <____> ALLERGIES: <____AllergiesNoReactions____> NURSING IMPRESSION: [ ] Strep Throat [ ] Sore Throat DISPOSITION OF CARE: [ ] RN advises antibiotic treatment according to UMHS Positive Strep Throat protocol. If not allergic to Penicillin: [ ] Rx. Pen VK 500 mg. BID x 10 days If unable to tolerate Pen VK: [ ] Rx Amoxicillin 1,000 mg. BID x 6 days. If allergic to Penicillin: [ ] Erythromycin 333mg. TID x 10 days [ ] If allergic to Penicillin and Erythromycin, consult Provider: <____> [ ] Faxed/Called to Pharmacy: <____> [ ] Patient to pick up prescription [ ] Comfort measures [ ] [ ] Per [ ] or [ ] Patient does meet criteria for Sore Throat Telephone Protocol Comfort measures Patient Preference: Acetaminophen 320 mg. every 6 -8 hours Ibuprofen 400 mg. every 6 -8 hours
PATIENT INSTRUCTION [ ] Avoid close contact with other people until you have been taking antibiotic for 24 -48 hours so they will not be exposed to streptococcal bacteria. [ ] Comfort measures as follows: increase fluids, vaporizer, salt water gargle, throat lozenges, avoid smoke, rest [ ] Hand washing is the best prevention against spreading infections. [ ] Patient instructed to complete all of prescribed treatment to ensure prevention or rheumatic fever. If sor e throat recurs, patient should be seen and re -evaluated. If generalized rash or hives develop stop medication and notify clinic. [ ] Patient restates plan and agrees to above plan. [ ] Yes, [ ] No; If no, explain: [ ] Provider action requested [ ] None [ ] Contact Patient [ ] Advise/Prescribe Related URL or References:
Seizure Pediatric Nursing Assessment, Vr. 2.0

Creation Date: 4/30/07 Created By: H. Murrel Approved Date: 4/30/07 Approved By: D. Kowalczyk Revised Date: 6/5/08
SEIZURE PEDIATRIC NURSING ASSESSMENT, Vr. 2.0 Return visit: <____> Current seizure meds: [ ] Missed doses (specify medication) : <____> When <____> [ ]Adverse effects: description <____> DESCRIPTION OF SEIZURE ACTIVITY (ASSESSMENT): Seizure frequency: <____> Duration of seizure activity: <____> [ ] Concurrent illness(describe): <____> Febrile [ ] [ ] Typical seizure for this child. See CareWeb note dated: <____> PRIOR TO SEIZURE [ ] Cried out [ ] Jerking of arms [ ] Right [ ]Left [ ] Legs [ ] Right [ ] Left [ ] Confusion [ ] Headache [ ] Emesis [ ] Disturbed/behavior [ ] Other (specify): <____> [ ] None of above DURING SEIZURE [ ] Fell [ ] Eyes turned [ ] Upward [ ] Right [ ]Left [ ] Body rigid [ ] Rhythmic Body Jerking [ ] Unconscious [ ] Cyanosis [ ] Emesis [ ] Response to stimuli present: (specify) [ ] Other (specify): <____> [ ] None of above POSTICTAL [ ] Soiled [ ] Urinated [ ] Bitten tongue [ ] Became confused [ ] Need to Sleep. Duration <____> [ ] Headache Afterwards [ ] Any injuries [ ] None of above Duration of Seizure <____> Additional information: NURSING IMPRESSION: <____>
Plan: [ ] Review with Physician [ ] Increase <____m edication> to: <____> [ ] Decrease <____medication> to: <____> [ ] Start new medication <____> [ ] Medication changes sent to pharmacy: Phone <____> fax <____> [ ] Labs repeat (specify): <____> [ ] day(s) [ ]week(s) [ ] month(s) PATIENT EDUCATION: Drug information and dosing instructions [ ] Discussed [ ] Mailed copy [ ] date <____> Seizure Emergency Care and Safety Issues Handout [ ] discussed [ ]Mailed date <____> [ ] Emergency contact after office hours given [ ] Caregiver aware of plan and verbali zes understanding of instructions and agrees to plan. Related URL or References:
Suture/Staple Removal, Vr. 3.0

Creation Date:
4/29/2005
Created By:
C. Laughlin
Approved Date:
4/29/2005
Approved By:
M. Kiss K. Ford
SUTURE/STAPLE REMOVAL, Vr. 3.0 This pt. returns today to have [ ] sutures [ ] staples removed per order of <____> [ ] Physician at an outside urgent center where the laceration was closed. Clinic provider consulted Name: <____> [ ] Physician at this facility Name: <____> The sutures/staples were placed <____> days ago. [ ] Yes [ ] No The patient states he/she is having pain or drainage at the wound site. If yes, RN or provider notified:<____> [ ] Yes [ ] No Wound is dry and edges of wound are together If no, RN or provider notified: <____> [ ] Yes [ ] No Sutures /staples removed Number removed: <____> Site(s): <____> Appearance of wound: <____> [ ] Steri-strips applied [ ] Dressing applied Other: <____> Patient tolerated the procedure well. Signs and symptoms of infection reviewed per patient handout and patient instructed when to call clinic.
Name/Title: <____> Related URL or References:
Travel Clinic Nursing Assessment, Vr. 2.0

Creation Date: 3/15/06 Created By: S. Olsson Approved Date: 3/15/06 Approved By: D. Kowalczyk Revised Date: 6/5/08
TRAVEL CLINIC NURSING NOTE, Vr. 2.0 Daytime Phone (Home) #: <____patientHomePhone____> Alternate Phone (Contact) #: <____ patientContactPhone____> Insurance: <____patientInsurance____> DRUG ALLERGIES: <____DrugAllergiesWithReactions____> DESTINATION: <____> DEPARTURE DATE: <____> DURATION OF TRIP: <____> PURPOSE OF TRIP: [ ] Missionary, School [ ] Vacation [ ] Adoption [ ] Agricultural [ ] Other ACCOMMODATIONS: [ ] Camping [ ] Dormitory [ ] Hostel [ ] Hotel [ ] Private Home [ ] Other (specify): VACCINES GIVEN (See Immunization Record): [ ] Hepatitis A [ ]adult [ ]pediatric(1 -19 years old) [ ] Hepatitis B [ ]adul t [ ]pediatric(1 -18 years old) [ ] IPV [ ] Japanese Encephalitis [ ] MMR [ ] MENINGOCOCCAL [ ] Medimmune [ ] Menactra (11 -55 years-old) [ ] Rabies [ ] Td [] Tdap [ ] Typhoid [ ] parenteral [ ] oral [ ] Varicella [ ] Yellow Fever NURSING IMPRESSION : <____> PRESCRIPTIONS GIVEN [ ] Rifaximin 200 mg. po TID x 3 days #9 [ ] Ciprofloxacin HCL 500 mg. PO BID x 3 -5 days #10 [ ] Azithromycin 500 mg. po daily x 3 days #3 [ ] Acetazolamide (Diamox) 250 mg. PO BID 24 hours prior to
ascent, continue for 4 8 hours after. ANTIMALARIALS [ ] Chloroquine Phosphate (Aralen) 500 mg. Take one tablet weekly. Begin one week before travel and continue until 4 weeks after travel to malarious areas. [ ] Malarone (Atovaquone 250 mg. /Proguanil 100 mg.) Take one tablet daily, starting one day before entering malarious areas. Continue until 7 days after leaving such areas. [ ] Doxycycline 100 mg. Begin 1 day prior to travel. Take one tablet daily and continue four weeks after return from malarious area. [ ] Mefloquine (Larium) 250 mg Take one tablet weekly. Start one week before travel; continue during travel in malarious areas and for 4 weeks after leaving such areas. PATIENT INSTRUCTIONS [ ] Food and water precautions [ ] Mosquito avoidance [ ] Safety issues: (S un exposure, Crime, STD, HIV) [ ] Verbalized understanding, advised to call back with questions, concerns, or vaccine reaction symptoms. [ ] Appointment advised [ ] Patient advised to follow -up with primary care physician for completion of hepatitis A/B series. Related URL or References:
Tuberculosis (TB) Screening Tool Nursing Note, Vr. 1.0

Approved Revised By: Date: HIM No response Billing TUBERCULOSIS (TB) SCREENING TOOL NURSING NOTE, Vr. 1.0 REASON FOR CALL/VISIT: Patient has positive TB test ASSESSMENT: Date of TB Test: <____> Size of Induration: <____> CHEST X-RAY Date: <____> Results: <____> CURRENT TB MEDICATIONS [ ] Oral Name of medication:<____> Strength: <____> Length of treatment: <____> SYMPTOMS [ ] Cough [ ] Fever [ ] Night sweats [ ] Fatigue Creation Date: 4/10/09 Created By: Sue Olsson Approved Date: 4/27/09
[ ] Other: <____> ADDITIONAL INFORMATION: [ ] History o f BCG vaccination or treatment [ ] Known exposure to someone with TB: <____> [ ] Foreign -born or extensive travel to countries with endemic TB: <____> [ ] Immune -compromised: <____> [ ] Other risk factors (Homelessness, Intravenous Drug Abuser, Incarcera tion): <____> NURSING IMPRESSION: TB Exposure DISPOSITION: [ ] Advised to schedule appointment with Primary Care Physician [ ] Appointment scheduled Date: <____> [ ] Caller advised to call back with questions, concerns, or change in symptoms. [ ] Patient instructed to obtain a mask before coming to clinic. Related URL or References:
Urgent Care Cancer Center Nursing Triage Note, Vr. 3.0

Creation Date: 11/06 Created By: A. Farless Approved Date: 11/6 Approved By: T. Niu Revised Date: 6/5/08
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URGENT CARE CANCER C ENTER NURSING TRIAGE NOTE, Vr 3.0 Contact Phone Number: <____patientContactPhone____> Diagnosis: <____> Most recent Treatment (chemo, blood products, etc): < ____> Date of Last Treatment: <____> Primary Provider Name and Contact Number: <____> ASSESSMENT: Chief Complaint: <____> Quality/severity (Pain Scale, if appropriate): <____> Onset: <____> Duration: <____> Modifying factor(s): <____> Associated signs and symptoms: <____> Comments: <____> NURSING ASSESSMENT: <____> PRESUMED DIAGNOSIS: <____> DIAGNOSTIC TEST(S): Laboratory: [ ] Complete Blood Count, Differential, Platelets (CDP) [ ] Basic [ ] Comprehensive Chemistry [ ] LDH
[ [ [ [ [ [ [ [ [
] ] ] ] ] ] ] ] ]
Magnesium Lipase Amylase Protime (PT) PTT Blood Cultures Urinalysis (UA) Urine Culture and Sensitivity (C&S) Other (Specify):
Radiology: [ ] CXR PA/Lateral [ ] CXR PA/Lateral, Decubitus [ ] Abdominal X -ray, flat/upright [ ] Acute Ab dominal Serial X -ray [ ] Abdominal Ultrasound [ ] CT Scan/specify: [ ] Doppler [ ] Other (Specify): PLAN: Appointment Time Requested : [ ] 1300 [ ] 1500 [ ] Other (Specify): Action Requested: [ ] Urgent Care will contact patient [ ] Urgent Care will schedule labs, test(s) [ ] Clinic will contact patient [ ] Clinic will schedule test(s) Comments: <____> Disposition: Appointment Date: <____> Appointment Time: <____> Related URL or References:
Urinary Tract Infection (UTI), Non-Pregnant Adult, Vr. 5.0

CreatedBy/CreationDate: C. Laughlin/4/29/2005 ApprovedBy/ApprovedDate: M. Kiss, K. Ford, E. Patrick-Dunlavey/4/29/2005
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RevisedBy/RevisedDate: D. Brown, C. Davies/6/5/08 and12/13/10 E. Patrick-Dunlavey (FGP), J. Pund, PPC, T. Jackson (HIM)/ 04/19/2011
URINARY TRACT INFECTION (UTI), NON -PREGNANT ADULT, Vr.5.0 ASSESSMENT: [ ] History of uncomplicated Urinary Tract Infection (UTI) with similar symptoms. If no, recommend physician appointment If yes, then date of last UTI: <____> Lower Tract Symptoms: [ ] dysuria [ ] urinary frequency
[ ] urinary urgency [ ] day [ ] [ ] [ ] [ ] Symptoms of pyelonephritis: If any of these, recommend same appointment: flank or back pain fever nausea or vomiting Pain (details): <____>
[ ] Symptoms of vaginitis: If any of t hese, refer to adult vaginitis protocol: [ ] vaginal discharge [ ] itching [ ] external burning [ ] Other (specify): <____> HISTORY: Complicating Factors: If any of these, recommend same day appointment [ ] Pregnancy [ ] Transplant [ ] Diabetic [ ] Syste mic steroid use [ ] Recent hospitalization [ ] Nursing home resident [ ] Chronic renal or urologic disease [ ] Other (specify): <____> [ ] Three or more UTI in the past 12 months. If yes, offer phone triage nurse management AND schedule office visit in near future to discuss management. NURSING IMPRESSION: URINARY TRACT INFECTION MEDICATION ALLERGIES: <____AllergiesWithReactions____> Describe: <____> DISPOSITION OF CARE: If patient. meets criteria for phone treatment of urinary symptoms, offer phone triage nurse management. If patient prefers office visit, schedule visit same day. [ ] The nurse advises phone treatment as follows: [ ] Bactrim DS (Sulfamethoxazole/Trimethoprim) 1 tab twice a day for 3 days, if no Sulfa allergy, or Macrobid (Nitrofuranto in) 100 mg BID for 5 -7 days [ ] Ciprofloxin 250 mg twice a day for 3 days (not in pregnant women) [ ] Macrobid 100 mg twice a day for 7 days [ ] Amoxicillin 500 mg three times a day for 7 days To relieve discomfort, offer [ ] Pyridium 100 mg three times a discomfort day #10 no refills, prn
[ ] Faxed/called to pharmacy: [ ] Patient to pick up prescription PATIENT INSTRUCTION GIVEN: Call office if: 1. Symptoms persist or worsen after 48 hrs
2. Fever, vomiting or rash develop 3. Symptoms recur after medica tion is finished If using Pyridium, inform patient that urine and tears turn orange (risk of staining soft contact lenses). Strategies for prevention of UTI per nursing protocol: urinate after intercourse, drink plenty of fluids [ ] Patient verbalized u nderstanding, states plan and agrees to above plan. If No, explain: <____> PROVIDER ACTION REQU ESTED: [ ] None [ ] Contact patient [ ] Advise/prescribe Related URL or References:
Work/School Excuse Note, Vr. 3.0

Creation Date: 7/24/06 Created By: P. Szymanski Approved Date: 7/24/06 Approved By: T. Niu Revised Date: 6/5/08
WORK / SCHOOL EXCUSE NOTE, Vr. 3.0 University of Michigan Healthcare System WORK /SCHOOL EXCUSE NOTE Health Center:<____> <____patientFirstLastName____> FIRST DAY UNABLE TO WORK OR ATTEND SCHOOL: <____> RETURN TO WORK / SCHOOL DATE: <____> ILLNESS / INJURY RELATED TO WORK / SCHOOL: Yes<____>No RESTRICTIONS: <____> SIGNATURE: <____> Related URL or References:
ABNORMAL LAB TEST
Abnormal Lab-Hematocrit (HCT) OB Results Management Note, Vr. 2.0

Creation Date:
10/1/2007
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Created By: Mary Wieszczyk and Barb Getty
Approved Date:
10/1/2007
Approved By:
H. Rodriguez
ABNORMAL LAB -HEMATOCRIT (HCT) OB - RESULTS MANAGEMENT NOTE, Vr 2.0 ASSESSMENT Gravida: <____> Para: <____> Last Menstrual Period: <____> Estimated Date of Delivery: <____> Allergies: <____AllergiesWithReactions____> Maternal illness/complications: <____> ABNORMAL LAB [ ] HCT: <____> NURSING IMPRESSION: Abnormal Hematocrit Result PLAN: PER UMHS Abnormal OB Laboratory Results Protocol, HCT section [ ] Patient notified of HCT value and pre scribed treatment [ ] Treat with Ferrous Sulfate 325mg [ ] For HCT 32 -35, take one tablet daily [ ] For HCT 30 -32, take one tablet, twice daily [ ] For HCT <30, take one tablet, three times a day [ ] Treat with Feosol 1 tab twice daily if patient can n ot tolerate Ferrous Sulfate [ ] PATIENT INSTRUCTION Encourage adequate diet per protocol Reinforce importance of prenatal vitamins Constipation instruction per protocol [ ] Patient verbalizes understanding and agrees with plan.
PROCEDURE TEMPLATE
Internal Medicine Procedure Templates
Code Note, Vr. 1.0 Procedure Note: Arterial Blood Gas, Vr. 1.0 Procedure Note: Arterial Line Placement, Vr. 3.0 Procedure Note: Central Line, Vr 1.0 Procedure Note: Intubation, Vr. 1.0 Procedure Note: Lumbar Puncture,,Vr. 1.0 Procedure Note: Patency Capsule, Vr. 1.0 Procedure Note: Paracentesis, Vr. 1.0 Procedure Note: Thoracentesis, Vr. 1.0
Code Note, Vr. 1.0

Creation Date: 9/7/2010 Created By: B Stein Approved Date: 5/21/2007 Approved By: M Kiss K Ford Revised Date:
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Revised By:
CODE NOTE, Vr 1.0 Called to patients bedside via code blue pager. Patient with past medical history significant for <____> evaluated and found to have <____> condition. <____INSERT brief summary of code____>. PROCEDURES PERFORMED: Intubation: <____> CPR: <____> Access Placement: <____> ABG: <____> Arterial Line: <____> Post Code Status: <____> Related URL or References:
Procedure Note: Arterial Blood Gas, Vr. 1.0

Creation Date: 9/7/2010 Created By: B Stein Approved Date: 5/21/2007 Approved By: M Kiss K Ford Revised Date: 9/7/2010
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Revised By: T. Jackson (HIM)
PROCEDURE NOTE: ARTERIAL BLOOD GAS, Vr. 1.0 <____> A time -out was completed verifying correct patient, procedure, site, positioning, and implant(s) or special equipment if applicable. Allens test was performed to ensure adequate perfusion. Patients right<____>left wrist was prepped and draped in usual sterile fashion. Lidocaine was<____> not used to anesthetize the area. A <____> gage needle was introduced into the artery with appropriate blood return. Estimated blood loss was <____minimal. Patient tolerated the procedure <____well and there were <___no complications. Related URL or References:
Procedure Note: Arterial Line Placement, Vr. 3.0

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Revised By:
PROCEDURE NOTE: ARTERIAL LINE PLACEMENT, Vr. 3.0 Date: <____> Time: <____> Indication: Hemodynamic monitoring Resident Surgeon: Attending Surgeon: <____> <____> A time -out was completed verifying correct patient, procedure, site, positioning, and implant(s) or special equipment if applicable. Allens test was performed to ensure adequate perfusion. The patients right <____> left wrist was prepped and draped in sterile fashion. 1% Lidocaine was <____> not used to anesthetize the area. A 18G <____> 20g Arrow arterial line was introduced into the radial <____> femoral artery. The catheter
was threaded over the guide wire and the needle was removed with appropriate pulsatile blood return. Blood loss was minimal. The catheter was the n sutured in place to the skin and a sterile dressing applied. Perfusion to the extremity distal to the point of the catheter insertion was checked and found to be adequate. Estimated Blood Loss :<____> Patient tolerated the procedure <____well and ther e were <____no complications. Related URL or References:
Procedure Note: Central Line, Vr 1.0

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Revised By:
PROCECURE NOTE: CENTRAL LINE Vr 1.0 <____> A time-out was completed verifying correct patient, procedure, site, positioning, and implant(s) or special equipment if applicable. Patients right<____>left was prepped and draped in usual sterile fashion. <____2% Lidocaine wasused to anesthetize the area. A Cordis<____>Triple lumen central line was introduced over a wire via the Seldinger technique and the catheter sutured into place. Good blood flow was <____> noted from the port(s). Blood loss was <____minimal. <____> Chest xray was ordered to as sess for pneumothorax and catheter placement. Patient tolerated the procedure <____well and there were <____no complications. Related URL or References:
Procedure Note: Intubation, Vr. 1.0

Creation Date: 5/21/2007 Created By: B Stein Approved Date: 5/21/2007 Approved By: M Kiss Revised Date: 9/7/2010
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Revised By: T. Jackson (Him)
K Ford PROCEDURE NOTE: INTUBATION, Vr. 1.0 <____>A time -out was completed verifying correct patient, procedure, site, positioning, and implant(s) or special equipment if applicable. Patient was evaluated and required intubation for <____>.
The patient was prepared in the usual fashion and a <____> French endotrachial tube was placed under direct visualization to <____> inches at the teeth. Bilateral breath sounds were heard without air sounds in the abdomen. An end -tital Co2 monitor was used to confirm tracheal placement of the ET tube. Estimated blood loss was <____>. Sedation/Paralyzation: <____> <____> Chest xray was ordered to assess for pneumothorax and endotracheal tube placement. Patient tolerated the proc edure <____well and there were <____no complications. Related URL or References:
Procedure Note: Lumbar Puncture, Vr. 1.0

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Revised By:
PROCEDURE NOTE: LUMBAR PUNCTURE, Vr. 1.0 <____> A time -out was completed verifying correct patient, procedure, site, positioning, and implant(s) or special equipment if applicable. Patient positioned, prepped and draped in usual sterile f ashion. The <____>L4 space was located using the iliac crests as landmarks. <____>1% Lidocaine wasused to anesthetize the area. A 22G spinal needle was introduced into the arachnoid space. The stylet was removed with appropriate fluid return. Needle re moved after adequate fluid collected. Blood loss was <____minimal. Opening pressure: <____> Fluid appearance: <____>
Sent for: <____Cell Count Gram Stain Cultures Glucose Protein Cytology Patient tolerated the procedure <____well and there were <____ no complications. Related URL or References:
Procedure Note: Patency Capsule, Vr. 1.0

Creation Date: 5/21/2007 Created By: J. Whelen Approved Date: 5/21/2007 Approved By: D. Kowalczyk Revised Date: 9/7/2010
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Revised By: T. Jackson (HIM)
Procedure Note Patency Capsule, Vr 1.0 PROCEDURE: Patency Capsule INDICATION: Evaluation for small bowel REFERRING MD: <____> DATE of procedure: <____> TIME of procedure: <____> RESULTS: NEGATIVE (capsule NOT retained) <____> POSITIVE (capsule retained) ESTIMATED BLOOD LOSS: <____> CAPSULE ENDOSCOPY SCHEDULED: YES <____> NO Related URL or References: obstruction.
Procedure Note: Paracentesis, Vr. 1.0

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Revised By:
PROCEDURE NOTE: PARACENTESIS, Vr. 1.0 <____> A time -out was completed verifying correct patient, procedure, site, positioning, and implant(s) or special equipment
if applicable Ultrasound guidance was<____>not used and appropriate fluid pocket was identified. Patient positioned, prepped and draped in usual sterile fashion. <____>1% Lidocaine was<____>not used to anesthetize the area. A <____> gage needle<____>angi ocath was introduced into the peritoneal space and fluid was removed. Blood loss was <____minimal. Total Fluid Removed: <____> Color of Fluid: <____> Sent for: <____Cell Count Gram Stain Cultures Albumin LDH Glucose Triglycerides Amylase Lipase Cytolog y Patient tolerated the procedure <____well and there were <____no complications. Related URL or References:
Procedure Note: Thoracentesis, Vr. 1.0

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Revised By:
PROCEDURE NOTE: THORACENTESIS, Vr. 1.0 <____> A time -out was completed verifying correct patient, procedure, site, positioning, and implant(s) or special equipment if applicable. Ultrasound guidance was<____>not used and appropriate fluid pocket was identified and marked. Patient was positioned, prepped and draped in usual sterile fashion. <_____>% Lidocaine was used to anesthetize the area. A <___> needle was introduced into the pleural space and fluid was removed. Blood loss was <____minimal. <____>A chest xray was ordered to evaluate for pneumothorax. Total Fluid Removed: <____> Color of Fluid: <____> Sent for: <____Cell Count Gram Stain Cultures LDH Glucose pH Cytology Patient tolerated the procedure <____well and there were <____n o
complications. Related URL or References:
PROCEDURE TEMPLATE
Nursing Discharge Note, Vr. 1.0

Creation Created Approved Date: By: Date: 2/28/06 J. Shlafer 3/2/06 NURSING DISCHARGE NOTE, Vr. 1.0 SUBJECTIVE: <____> OBJECTIVE: Pt discharged at <____>, with <____>, to: [] Home Health Care with Services [] Home Self Care [] Extended Care Facility [] Acute Care Facility Temperature: <____> Heart Rate: <____> Blood pressure: <____> O2 Sat (if applicable): <____> Weight: <____> 1. Nursing Diagnosis: <____> Analysis: <____> Plan: <____> 2. Nursin g Diagnosis: <____> Analysis: <____> Plan: <____> 3. Nursing Diagnosis: <____> Analysis: <____> Plan: <____> 4. Nursing Diagnosis: <____> Analysis: <____> Plan: <____> 5. Nursing Diagnosis: <____> Analysis: <____> Plan: <____> Related URL or References: Approved By: Tori Niu Revised Date:
Nursing Event Note, Vr. 1.0

Creation Created Approved Date: By: Date: 2/28/06 J. Shlafer 3/2/06 NURSING EVENT NOTE, Vr. 1.0 EVENT: <____> SUBJECTIVE: <____> OBJECTIVE: <____> Approved By: Tori Niu Revised Date:
ANALYSIS: <____> PLAN: <____>
Nursing Event Note Blood, Vr. 2.0

Creation Date: 10/06 Created By: J. Shalfer Approved Date: 10/06 Approved By: T. Niu
Back to Top Revised Date: 7/1/09 Revised By: D. Willis B. Myers HIM
NURSING EVENT NOTE BLOOD, Vr. 2.0 SUBJECTIVE: [ ] no complaints related to transfusion [ ] complained of <____> OBJECTIVE: Type of Blood Product Administered: Also see Transfusion Record and eMAR [ ] PRBC: # of units: < ____> [ ] Platelets: # of 5 packs: <____> [ ] FFP: # of units: <____> [ ] Other (Specify type and # of units): <____> Premedications Given: [ ] Tylenol see eMAR [ ] Benadryl see eMAR [ ] None ordered [ ] Other: <____> Patient and/or Family Instructe d re: [ ] Rationale for transfusion [ ] Signs/symptoms of potential reaction and to notify nurse [ ] Post-Transfusion Instructions handout provided/ reviewed; instructed to notify primary care provider if symptoms develop following discharge http://www.pathology.med.umich.edu/bloodbank/POD0271 PostTransfusionInstructions109.pdf [ ] No instruction given due to: [ ] Confused [ ] Comatose [ ] Previously instructed [ ] Other (specify): <____> Patient Observation: [ ] Vital signs stable throughout see [ ] Transfusion Record or [ ] Flowsheet [ ] No adverse signs/symptoms noted (e.g. chest pain, SOB, fever, chills, diaphoresis, hives, rash, pruritus)
[ ] Noted Signs/Symptoms of <____>. Treatment/follow -up done: <____> [ ] Other (Specify): <____> ANALYSIS: [ ] Patient tolerated transfusion w/o complication [ ] Possible reaction noted Dr. <____> aware (primary team); Blood Bank following [ ] Unable to com plete blood product due to <____>; Dr. <____> aware [ ] Other (Specify): <____> PLAN: [ ] Blood complete; no further acute monitoring required [ ] Additional transfusions ordered continue on next shift [ ] Continue to monitor for post -transfusion delay ed reactions [ ] Continue to monitor lab results (e.g. CBC, coags) [ ] Other (Specify): <____> http://www.pathology.med.umich.edu/bloodbank/POD0271 Related URL or PostTransfusionInstructions109.pdf References:
Nursing Event Note Fall, Vr. 3.0

Creation Date: 10/06 Created By: S. Finks Approved Date: 10/06 Approved By: T. Niu Revised Date:
1/7/09 1/29/09 2/13/09 12/9/09
Back to Top Revised By: B. Myers
NURSING EVENT NOTE FALL, Vr. 3.0 Date/Time of Fall/Near Fall: <____> Location of Fall/Near Fall: Building/room #: <____> PRE-FALL Orientation Person [ ] Yes [ ] No Place [ ] Yes [ ] No Time [ ] Yes [ ] No Situation [ ] Yes [ ] No Gait Imbalance [ ] Yes [ ] No [ ] Unknown Incontinence [ ] Yes [ ] No Recent change in Mental Status [ ] Yes [ ] No Recent change in Medication (last 48 hrs) [ ] Yes [ ] No POST-FALL/NEAR FALL SUBJECTIVE: Patient Statement: <____> OBJECTIVE: Describe Event: <____> Witnessed: [ ] Yes [ ] No If yes, person who witnessed the fall: <____> Activity at Time of Fall/Near Fall: [ ] Unknown, found on floor [ ] Ambulating in hallway [ ] Ambulating in room [ ] Ambulating to/from bathr oom [ ] Climbing out of bed [ ] In shower [ ] On bedside commode [ ] On toilet [ ] Up in chair [ ] Up in wheelchair Transferring from: [ ] Bed [ ] Stretcher [ ] Wheelchair Transferring to: [ ] Bed [ ] Stretcher [ ] Wheelchair [ ] Other (specify): <____ > Safety Measures at the time of Fall/Near Fall: Siderails up: [ ] x1 [ ] x2 [ ] x3 [ ] x4 [ ] N/A Restraints: [ ] Soft wrist [ ] Leather [ ] Posey vest Call light/emergency cord within reach: [ ] Yes [ ] No [ ] N/A Sitter assigned this shift: [ ] Yes [ ] No Sitter present at bedside: [ ] Yes [ ] No [ ] N/A Fall Precautions: [ ] Yes [ ] No [ ] N/A [ ] Bed [ ] Stretcher in low position: [ ] Yes [ ] No [ ] N/A [ ] Bed [ ] Stretcher in locked position:[ ] Yes [ ] No [ ] N/A Non-skid footwear: [ ] Yes [ ] No [ ] N/A Wheelchair in locked position: [ ] Yes [ ] No [ ] N/A Bed Alarm system in use [ ] Yes [ ] No [ ] N/A Patient Assessment Post Fall/Near Fall: Vitals: BP <____> HR <____> RR <____> Orthostatic BP/HR (as needed) <____> O2/Pulse Ox <____> CBG <____> Orientation: Person [ ] Yes [ ] No Place [ ] Yes [ ] No Time [ ] Yes [ ] No Situation [ ] Yes [ ] No
Injury: [ ] No Apparent Injury [ ] Abrasion/cut/tear/laceration [ ] Bruise/Contusion [ ] Bleeding/hemorrhage [ ] Fracture [ ] Loss of Consciousness [ ] Pain [ ] Swelling [ ] Other (specify): <____> Description/Location of Injury: <____> ANALYSIS: Patient Status: <____> PLAN/INTERVENTIONS: <____> Family Notified: Patient making his/her own decisions: [ ]Yes [ ]No IF YES: [ ] Family notified at patients request: (Date/Time) <____> [ ] Patient declined family notification OR IF NO or pediatrics< 18years: [ ] Family notified of fall: (Date/Time) <____> Physician Notified: Name: <____> Physician ID#: <____> Date/Time of notification: <____> Safety Measure s Post Fall/Near Fall: Care plan updated: [ ] Yes [ ] No [ ] N/A Fall Precautions Initiated: [ ] Yes [ ] Already in Place Sitter requested: [ ] Yes [ ] No [ ] N/A Family at Bedside: [ ] Yes [ ] No [ ] N/A Bed Alarm system activated [ ] Yes [ ] No [ ] N/A Patient re-oriented to call light and other safety measures: [ ] Yes [ ] No Other interventions indicated: [ ] Yes [ ] No If yes, describe: <____>
Nursing Progress Note, Vr 2.0

Creation Date: 2/28/06 Created By: J. Shlafer Approved Date: 3/2/06 Approved By: Tori Niu Revised Date: 7/1/09
Back to Top Revised By: D. Willis B. Myers HIM
NURSING PROGRESS NOTE, Vr 2.0 SUBJECTIVE: <____> OBJECTIVE: <____> 1. Nursing Diagnosis: <____> Analysis: <____> Plan: <____> [ ] Initiate nursing plan of care [ ] Continue per nursing plan of care [ ] Revise nursing plan of care [ ] Nursing diagnosis/plan of care resolved 2. Nursing Diagnosis: <____> Analysis: <____> Plan: <____> [ ] Initiate nursing plan of care [ ] Continue per nursing plan of care [ ] Revise nursing plan of care [ ] Nursing diagnosis/plan of care resolved 3. Nursing Diagnosis: <____> Analysis: <____> Plan: <____> [ ] Initiate nursing plan of care [ ] Continue per nursing plan of care [ ] Revise nursing plan of care [ ] Nursing diagnosis/plan of care resolved 4. Nursing Diagnosis: <____> Analysis: <____> Plan: <____> [ ] Initiate nursing plan of care [ ] Continue per nursing plan of care [ ] Revise nursing plan of care [ ] Nursing diagnosis/plan of care resolved 5. Nursing Diagnosis: <____> Analysis: <____> Plan: <____> [ ] Initiate nursing plan o f care [ ] Continue per nursing plan of care [ ] Revise nursing plan of care [ ] Nursing diagnosis/plan of care resolved Related URL or References:
PICC Line Placement, Vr 1.0

Creation Created Approved Date: By: Date: 7/10/08 M. Merkel 7/10/08 PICC LINE PLACEMENT, Vr. 1.0 Date/Time <____> Indication for PICC Line Placement: <____> Sedation/Analgesia: <____> Prep: <____> Approved By: D. Kowalczyk Revised Date:
A<____> Gauge, <____> cm. <____>Percutaneously placed Peripherally Inserted Central Catheter was introduced via the patients <____> vein, and advanced <____> cm. There was easy aspiration of blood back into the catheter upon insertion, and 0.9% Sodium Chloride with 1 unit of heparin per ml. was flus hed through the line without difficulty for a total of <____> ml. Line tip position was confirmed by x -ray (CXR/ABD). The film was reviewed by <____> and tip was reported to be <____> An occlusive dressing was applied. This catheter was from manufacture Patient tolerance of procedure: <____> [ ] Correct patient identity, correct side and site of procedure to be done and agreement on procedure to be done checked prior to initiation of procedure. Additional Comments: <____> Related URL or References: lot number <____>
FALL TEMPLATE
Falls with Possible Harm - Physician Note, Vr 1.0

Approved By: HIM - R. Sitko Billing N/A FALLS WITH POSSIBLE HARM - PHYSICIAN NOTE, VR. 1.0 Creation Date: 2/13/09 Created By: M. Thompson Approved Date: 2/13/09 Revised Date: 2/27/09 3/13/09
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Revised By: B. Myers
Adult Inpatients with Suspected Head Trauma or Musculoskeletal Trauma Resulting from Fall DATE/TIME OF FALL: <____> Brief Description of Fall Event: <____> Location: <____> INJURY RISK FACTORS:(check all that apply) [ ] Anticoagulated: specify type below: [ ] Warfarin (coumadin) [ ] Heparin or Low Molecular Weight Heparin [ ] Aspirin or Clopidogrel (Plavix) Most recent INR = <____> Most recent PTT = <____> [ ] Low platelet count: Most recent platelet count = <____> [ ] Other Bleeding Risk <____> [ ] Previous DEXA scan with DX of osteoporosis or fracture (hip, wrist or vertebral) or Post -menopausal female PHYSICAL EXAM POST -FALL Oriented to: [ ] person [ ] place [ ] time [ ] situation Vital signs - include orthostatic readings (lying/standing) if possible: <____> Chemstick (if at risk for hypoglycemia): <____> Assess for possible head trauma: [ ] No trauma present [ ] Head trauma present: Describe: <____> Assess mental status: [ ] No change in mental status [ ] Post-fall change in mental status: Describe: <____> Assess for change in neurological status/muscular function: [ ] No change present [ ] Change i n symmetrical movements/strength: Describe: <____> [ ] Change in balance or gait: Describe: <____> [ ] Other: Describe: <____> Assess for possible musculoskeletal or spine injury: [ ] No musculoskeletal injury present [ ] Possible wrist fracture (deformi ty, pain, swelling, other) Describe: <____> [ ] Possible hip fracture (shortened leg length, limited or painful external rotation): Describe: <____> [ ] Pain in cervical spine [ ] Other: (i.e. dislocation, sprain, etc) Describe: <____> Assess for possibl e lacerations/skin injury : [ ] laceration site: <____> Describe: <____>
PLAN: [ ] Acute medical treatment needed (i.e. correction of anticoagulation, etc.): Describe: <____> [ ] Ordered Head CT scan: Rationale: <____> [ ] Ordered X -ray of <____>: Rational e: <____> [ ] Ordered EKG: Rationale: <____> [ ] Frequent neuro checks ordered: Rationale: <____> [ ] Family notified: Who <____> [ ] Medications reviewed no modifications needed [ ] Medications reviewed will modify: Describe: <____> [ ] Consults reque sted (if applicable): [ ] Orthopedics or Trauma [ ] Neurosurgery [ ] Plastic Surgery [ ] Other (specify): <____>

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Insulin Adjustment - Medication Management Note, Vr. 2.

Revised By: D. Brown C. Davies

Medication Authorization Status Medication Management Note, Vr. 2.0

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Medication Management Note,

Prescription Renewal/Prescription Authorization/Medication Information, Vr. 3.0

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Prescription Authorization Request Medication Management Note, Vr. 3.0

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Oral and Injectable Anti-Diabetic Medication Management Note, Vr. 1.0

Allergy Injection - Patient Instructions, Vr. 2.0

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Dry Powder Inhaler - Patient Instructions, Vr.

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EPINEPHRINE AUTO -INJECTOR - PATIENT INSTRUCTION, Vr.1.0

Gynecology Procedure Patient Discharge Instructions, Vr. 1.0

Approved By: HIM Billing

Liver Biopsy Patient Prep Instructions, Vr. 1.0

Methacholine Challenge Test - Patient Instructions, Vr. 2.0

Revised By: D. Brown C. Davies

Test Prep - Patient Instructions, Vr. 3.0

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Sildenafil Citrate (Viagra) - Patient Instructions,Vr. 2.0

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Testing Instructions Pre-Transplant Patient Instructions, Vr. 3.0

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Allergen Immunotherapy Systemic Reaction Nurse Visit Note, Vr. 5.0

Adult Blood Pressure Check, Vr. 2.0

Back to Top Revised Date: 6/5/08 Revised By: D. Brown C. Davies

Chemotherapy Infusion Nursing Note, Vr. 2.0

Back to Top Revised By: D. Brown C. Davies

Chronic Pain Management Nurse Visit Note, Vr. 2.0

Revised By: D. Brown C. Davies

Related URL or References:

Depo-Provera Nursing Note, Vr. 2.0

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Depo-Provera, Vr. 2.0

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Revised Date: 6/5/08

Revised By: D. Brown C. Davies

DEPO-PROVERA, Vr. 2.0

Dermatology Treatment Discharge Care Plan Nursing Note, Vr. 1.0

Dermatology Treatment Nursing Assessment, Vr. 1.0

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Diagnostic Testing (Pediatric Infusion) Nursing Note, Vr 1.0

Dressing Change, Vr. 2.0

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Revised Date: 6/5/08

Revised By: D. Brown C. Davies

Ear Irrigation, Vr. 2.0

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Revised Date: 6/5/08

Revised By: D. Brown C. Davies

Epinephrine Auto Injector- Patient Instruction, Vr.1.0

Headache Assessment Pediatric Neurology Nursing Note, Vr. 2.0

Revised By: D. Brown C. Davies

Patty Lindsay-Carr Mary Sue Webb Diane Brown

Immune Globulin Intravenous (IVIG) Infusion Nursing Note, Vr. 2.0

Injection/Medication (Pediatric Infusion) Nursing Note, Vr. 2.0

Revised By: D. Brown C. Davies

Intravenous Infusion Nursing Note, Vr. 1.0

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Lupron Depot Nursing Note, Vr. 2.0

ANALYSIS: <> PLAN: <>