Premier Home Health Care

Transitional Care

RN CARDIAC (CHF) CLINICAL PATHWAY - Visit 5

  • 1 Expected Outcomes
  • 2 Interventions
  • 3 Signature

Patient will avoid rapid weight gain

select "Yes" or "No"

Vital signs will be within patient’s normal limits

select "Yes" or "No"

Patient will verbalize understanding of need to follow up with regular PCP appointments

select "Yes" or "No"

Patient will develop realistic plan to maintain compliance post discharge

select "Yes" or "No"

Patient will verbalize knowledge of telehealth follow-up post discharge

select "Yes" or "No"

Complete patient assessment

select "Yes" or "No"

Discuss discharge plans or needs for alternate services

select "Yes" or "No"

Identify community supports available to ensure safe discharge to the community

select "Yes" or "No"

Identify evidence of patient’s compliance with the Plan of treatment

select "Yes" or "No"

Assess patient’s understanding of S&S to report to RN

select "Yes" or "No"

Provide needed information to teach patient about telehealth follow-up

select "Yes" or "No"

Coordinate with clinical team as needed

select "Yes" or "No"

Finished

Please sign here! Go to Visit 6