Transitional Care

RN COPD CLINICAL PATHWAY - Visit 6

  • 1 Expected Outcomes
  • 2 Interventions
  • 3 Signature

Patient will verbalize actions to access community resources

select "Yes" or "No"

Patient will demonstrate optimal level of independence in ADLs/IADLs

select "Yes" or "No"

Patient will demonstrate ability to maintain safety in home environment

select "Yes" or "No"

Patient will attain pulmonary stability

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"

Evaluate patient’s compliance with self-monitoring of disease process

select "Yes" or "No"

Discuss the benefits of the annual flu shot and the pneumonia vaccine if over 65, or under 65 with risk factors

select "Yes" or "No"

Assess current ADLs/IADLs activity and tolerance levels

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 7