Physician Orders for Life-Sustaining Treatment (POLST)



DHS: Senior and People with Disabilities

State Operated Community Program

SOCP Nurse Tools: | |

|SOCP Eliot Group Home – Nursing Assessment and Plan |

|Client name: |

|Subjective description: |

|Explain:       |

|Primary diagnosis: |

|Explain:       |

|Secondary diagnosis: |

|Explain:       |

|Code status: |

|Explain:       |

|Exams: most current / upcoming |

|Physical: |Psych.: |Pulmonary |

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|Labs: |Dental: |Neurology |

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|Eye: |Hearing: |Cardiac: |

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|Mammogram: |Pap/pelvic: |Podiatry: |

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|List all current medications |

|Current medications |Dosage |Reason |

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|List all current treatments |

|Current medications |Dosage |Reason |

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|List all current PRN to include - Self administered medications |

|Current medications |Dosage |Reason |

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|Immunizations Records |

| Polio |

|Mumps |

|German Measles/Rubella |

|Chickenpox/Varicella |

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|Measles / Rubeola |

|Diptheria |

|Tetanus (lockjaw) |

|Whooping Cough (Pertussis) |

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|Haemophilus typeB (Hib) |

|Hepatitis B |

|Hepatitis A |

|Other:       |

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|Polio |

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|Systems / number Was plan initiate: |Yes / No |Systems / number Was plan initiate: |Yes / No |

|H1 – Skin / scalp |      |H14,H15 /Allergies/adverse drug reactions |      |

|H2, H3, H4 / Orthopedic / Mobility |      |H16 / Nutrition / Hydration |      |

|H5 / Dental |      |H17 / Chewing / Swallowing |      |

|H6 / Eyes and Vision |      |H18 / Bowels |      |

|H7 / Ears and hearing |      |H19 / Stomach / Intestines |      |

|H8 / Respiratory |      |H20 / Hematology / Lymphatic |      |

|H9 / Injury |      |H21 / Urogenital |      |

|H10, H11 / Neurology/Seizures |      |H22 / Endocrine |      |

|H12 / Behaviors |      |H23 / Other |      |

|H13 / Cardiac / Vascular |      | | |

|Systems review |History / Subjective / Objective |

|H1: Skin / scalp |

|Problem(s):       |

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|At risk for:       |

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|Interventions:       |

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|Interval history       |

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|Current status:       |

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|Recommendations:       |

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|H2, H3, H4: |

|Orthopedic / Mobility |

|Problem(s):       |

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|At risk for:       |

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|Interventions:       |

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|Interval history       |

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|Current status:       |

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|Recommendations:       |

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|H5: Dental |

|Problem(s):       |

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|At risk for:       |

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|Interventions:       |

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|Interval history       |

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|Current status:       |

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|Recommendations:       |

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|H6: Eyes and Vision |

|Problem(s):       |

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|At risk for:       |

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|Interventions:       |

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|Interval history       |

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|Current status:       |

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|Recommendations:       |

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|H7: Ears and hearing |

|Problem(s):       |

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|At risk for:       |

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|Interventions:       |

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|Interval history       |

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|Current status:       |

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|Recommendations:       |

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|H8: Respiratory |

|Problem(s):       |

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|At risk for:       |

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|Interventions:       |

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|Interval history       |

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|Current status:       |

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|Recommendations:       |

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|H9: Injury |

|Problem(s):       |

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|At risk for:       |

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|Interventions:       |

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|Interval history       |

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|Current status:       |

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|Recommendations:       |

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|H10, H11: Neurology/Seizures |

|Problem(s):       |

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|At risk for:       |

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|Interventions:       |

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|Interval history       |

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|Current status:       |

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|Recommendations:       |

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|H12: Behaviors |

|Problem(s):       |

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|At risk for:       |

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|Interventions:       |

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|Interval history       |

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|Current status:       |

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|Recommendations:       |

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|H13: Cardiac / Vascular |

|Problem(s):       |

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|At risk for:       |

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|Interventions:       |

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|Interval history       |

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|Current status:       |

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|Recommendations:       |

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|H14,H15: Allergies/adverse drug reactions |

|Problem(s):       |

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|At risk for:       |

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|Interventions:       |

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|Interval history       |

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|Current status:       |

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|Recommendations:       |

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|H16: Nutrition / Hydration |

|Problem(s):       |

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|At risk for:       |

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|Interventions:       |

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|Interval history       |

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|Current status:       |

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|Recommendations:       |

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|H17: Chewing / Swallowing |

|Problem(s):       |

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|At risk for:       |

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|Interventions:       |

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|Interval history       |

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|Current status:       |

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|Recommendations:       |

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|H18: |

|Bowels / Elimination |

|Problem(s):       |

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|At risk for:       |

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|Interventions:       |

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|Interval history       |

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|Current status:       |

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|Recommendations:       |

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|H19: |

|Stomach / Intestines |

|Problem(s):       |

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|At risk for:       |

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|Interventions:       |

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|Interval history       |

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|Current status:       |

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|Recommendations:       |

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|H20: Hematology / Lymphatic |

|Problem(s):       |

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|At risk for:       |

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|Interventions:       |

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|Interval history       |

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|Current status:       |

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|Recommendations:       |

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|H21: Urogenital |

|Problem(s):       |

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|At risk for:       |

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|Interventions:       |

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|Interval history       |

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|Current status:       |

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|Recommendations:       |

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|H22: Endocrine |

|Problem(s):       |

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|At risk for:       |

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|Interventions:       |

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|Interval history       |

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|Current status:       |

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|Recommendations:       |

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|H23: Other |

|Problem(s):       |

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|At risk for:       |

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|Interventions:       |

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|Interval history       |

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|Current status:       |

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|Recommendations:       |

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|Nursing goal(s) for client: |

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|RN name (print): |      |Date: |      |

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|RN signature: | |Date: |      |

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