Premier Home Health Care
Transitional Care
Visits List
RN DIABETES CLINICAL PATHWAY - Visit 1
Validation
1
Expected Outcomes
2
Interventions
3
Signature
Patient will verbalize s/s to be reported immediately
Yes
No
select "Yes" or "No"
Patient will verbalize understanding of compliance to medication schedule
Yes
No
select "Yes" or "No"
Patient verbalizes understanding of POC/services, including telehealth
Yes
No
select "Yes" or "No"
Patient will verbalize understanding of how/when to contact agency
Yes
No
select "Yes" or "No"
Patient will verbalize understanding of when to go to ER/call 911
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 need for Rehab &/or HHA
Yes
No
select "Yes" or "No"
Assess readiness to learn
Yes
No
select "Yes" or "No"
Complete med reconciliation
Yes
No
select "Yes" or "No"
Instruct on how to contact agency
Yes
No
select "Yes" or "No"
Instruct on emergency measures
Yes
No
select "Yes" or "No"
Instruct on s/s hypo/ hyperglycemia, appropriate interventions and prevention measures
Yes
No
select "Yes" or "No"
Assess for glucometer in the home: functionality, assess pt/caregiver ability to use. If no glucometer, request Rx from MD/NP. If glucometer present, check and document the current finger stick. Instruct alert parameters for notification of the NP/MD
Yes
No
select "Yes" or "No"
Assess ability to self-administer insulin
Yes
No
select "Yes" or "No"
Discuss/collaborate on POC. Include discussion on telehealth as part of Plan of Treatment
Yes
No
select "Yes" or "No"
Initiate discussion on discharge plan
Yes
No
select "Yes" or "No"
Coordinate with the clinical team as needed
Yes
No
select "Yes" or "No"
Finished
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1
Validation states
2
Alerts
3
Payment Info
4
Other Info
Step 1
Step 2
Step 3
Step 4