Premier Home Health Care
Transitional Care
Visits List
RN CARDIAC (CHF) CLINICAL PATHWAY - Visit 1
Validation
1
Expected Outcomes
2
Interventions
3
Signature
Patient will verbalize S&S to be reporeted immediately
Yes
No
select "Yes" or "No"
Patient will verbalize knowledge of plan of treatment: medication, diet and daily weights
Yes
No
select "Yes" or "No"
Review inpatient discharge summary
Yes
No
select "Yes" or "No"
Complete comprehensive assessment
Yes
No
select "Yes" or "No"
Assess patient's knowledge of disease process
Yes
No
select "Yes" or "No"
Assess readiness to learn
Yes
No
select "Yes" or "No"
Identify potential barriers to compliance with Plan of treatment
Yes
No
select "Yes" or "No"
Initiate education as needed re: diet- low sodium, medication compliance, daily weights ( at the same time in the same type of clothing) and S&S to report to MD/RN
Yes
No
select "Yes" or "No"
Implement food log
Yes
No
select "Yes" or "No"
Implement weight log
Yes
No
select "Yes" or "No"
Complete med reconciliation process
Yes
No
select "Yes" or "No"
Discuss telehealth as part of Plan of Treatmen
Yes
No
select "Yes" or "No"
Assess for the presence of social supports
Yes
No
select "Yes" or "No"
Assess need for Therapies
Yes
No
select "Yes" or "No"
Coordinate with the clinical team as needed
Yes
No
select "Yes" or "No"
Finished
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Validation states
2
Alerts
3
Payment Info
4
Other Info
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