Nursing

DOB:

Address:

Payor Source:

Secondary Source:

1. Current Problems With Status Summary (Write a brief summary of current and co-morbid illnesses and the reason for care coordination planning.)

2. Routine Health Maintenance

Physician:

Physician’s Address:

Physician’s Phone Number:

Preferred Hospital:

General Dentist:

Dentist’s Address:

Dentist’s Phone Number:

Pharmacy:

Pharmacy’s Address:

Pharmacy’ Phone Number:

3. Specialty Care

Specialist One:

Discipline:

Physician’s Address:

Physician’s Phone Number:

Treatment Goals:

Specialist Two:

Discipline:

Physician’s Address:

Physician’s Phone Number:

Treatment Goals:

Specialist Three:

Discipline:

Physician’s Address:

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Physician’s Phone Number:

Treatment Goals:

Specialist Four:

Discipline:

Physician’s Address:

Physician’s Phone Number:

Treatment Goals:

4. Mental Health Provider

Specialist One:

Discipline:

Provider’s Address:

Provider’s Phone Number:

Treatment Goals:

5. Hospital Care (List history of hospitalizations.)

Date of Hospitalization:

Hospital Name:

Reason:

Length of Stay:

Discharged to Location:

Date of Hospitalization:

Hospital Name:

Reason:

Length of Stay:

Discharged to Location:

Date of Hospitalization:

Hospital Name:

Reason:

Length of Stay:

Discharged to Location:

6. Patient Education (List any educational program or coordination that the patient has completed.)

Name of Program:

When:

Where:

Name of Program:

When:

Where:

Name of Program:

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When:

Where:

Name of Program:

When:

Where:

7. Rehabilitation Services (List any rehabilitation stays, including in-patient, out-patient, Long Term Acute Care (LTAC), or Skilled Nursing Facility (SNF) stays.)

Name of Rehabilitation Services:

When:

Where:

Length of Stay:

Name of Rehabilitation Services:

When:

Where:

Length of Stay:

Name of Rehabilitation Services:

When:

Where:

Length of Stay:

Name of Rehabilitation Services:

When:

Where:

Length of Stay:

8. Medication List (List all medications, dosage, and purpose.)

Medication:

Dosage:

Purpose:

Medication:

Dosage:

Purpose:

Medication:

Dosage:

Purpose:

Medication:

Dosage:

Purpose:

Medication:

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Dosage:

Purpose:

9. Durable Medical Equipment

Equipment Owned:

Provider:

Equipment Rented:

Provider:

Equipment Ordered:

Provider:

Equipment Needed:

Provider:

Incontinence Equipment:

Provider:

10. Home Health Care Infusion Supplies

Enteral Nutrition Provider:

Phone Number:

Parenteral Infusion Provider:

Phone Number:

11. Other Services

Social Services:

Transition Services:

Transportation Services:

12. Nursing

Skilled Nursing Visits

Name:

Services:

Indication

Treatment Goals:

Hourly Nursing Services

Name:

Services:

Indication:

Treatment Goals:

Respite Care

Name:

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Services:

Indication:

Treatment Goals:

Hospice Care

Name:

Services:

Indication:

Treatment Goals:

13. Community Services/Referrals

14. Cultural Needs

15. Signatures

RN Care Coordinator

Patient

Patient Contact Information (e-mail or phone)

1

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