Premier Home Health Care

Transitional Care

RN CJR PATHWAY - Visit 1

  • 1 Expected Outcomes
  • 2 Interventions
  • 3 Signature

Patient will verbalize S&S to be reported immediately, including S&S of wound infection, DVT, and PE

select "Yes" or "No"

Patient will verbalize knowledge of plan of treatment: medications, therapies, additional services and telehealth

select "Yes" or "No"

Patient will verbalize knowledge of the plan for staples removal and follow-up with Orthopedic services

select "Yes" or "No"

Patient will verbalize knowledge of pain management techniques

select "Yes" or "No"

Patient will verbalize plan to meet basic ADL’s/IADL’s needs

select "Yes" or "No"

Review inpatient discharge summary

select "Yes" or "No"

Complete comprehensive assessment

select "Yes" or "No"

Assess patient’s knowledge of aftercare of joint procedure

select "Yes" or "No"

Assess readiness to learn

select "Yes" or "No"

Identify potential barriers to compliance with Plan of treatment

select "Yes" or "No"

Provide education on joint aftercare related to incision site and MD follow-up

select "Yes" or "No"

Initiate education as needed re: medication compliance, and S&S of infection at incision site, DVT, or PE; and pain management

select "Yes" or "No"

Provide education on sharps disposals if patient is on injectable anticoagulant

select "Yes" or "No"

Complete med reconciliation process

select "Yes" or "No"

Discuss plan of treatment including discharge of nursing service and initiation of therapy services

select "Yes" or "No"

Discuss telehealth as part of Plan of Treatment

select "Yes" or "No"

Assess for the presence of social supports

select "Yes" or "No"

Assess need for HHA services

select "Yes" or "No"

Coordinate with the clinical team as needed

select "Yes" or "No"

Finished

Please sign here! Go to Visit 2