| |
CARE PLAN |
| TITLE | FIRST NAME | SURNAME | ADMITTED FROM | ASSESSOR |
| . | |
|
| ADMISION DATE | DATE OF BIRTH | NAMED NURSE |
| ADDRESS OF PATIENT |
TEL | ||
| NEXT OF KIN | RELATIONSHIP | |
|
| ADDRESS . |
TEL |
MEDICAL HISTORY |
DOCTOR | TEL | |
| DIAGNOSIS | |
| COMMENTS | |
| MEDICATION | |
| ALLERGIC TO |
| REASON FOR ADMISSION | |
| COMFORT & MOBILITY | |
| COMMUNICATION | |
| ACTIVITIES | |
| CLOTHING | |
| PERSONAL CARE | |
| HYGIENE | |
| MENTAL ALERTNESS | |
| DIET | |
| CONTINENCE | |
| ANXIETIES | |
| RELAXATION & SLEEP | |
| PAST OCCUPATION | |
| INFORMATION GIVEN | |
| DSS LA AA | |
| SOCIAL WORKER | |
| DYING WITH DIGNITY | |
| CHANGES |
HOSPITAL HISTORY |
HOSPITAL | TEL | |
| LAST VISIT | |
| COMMENTS | |
| . | |
| . |
| STAFF SIGNATURE | PATIENT/REPRESENTATIVE SIGNATURE |
| STAFF NAME & POSITION | NAME |