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: | |
| | | |signature | | |
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