Premier Home Health Care

Transitional Care

RN DIABETES CLINICAL PATHWAY - Visit 4

  • 1 Expected Outcomes
  • 2 Interventions
  • 3 Signature

Patient will verbalize knowledge of disease process

select "Yes" or "No"

Patient will demonstrate increased participation with ADL/IADLs

select "Yes" or "No"

Patient will demonstrate improved functional status

select "Yes" or "No"

Patient will verbalize knowledge of and demonstrate compliance with medication & diet

select "Yes" or "No"

Patient will demonstrate proper foot/skin assessment

select "Yes" or "No"

Check and document the current finger stick. Assess bg log and Notify NP/MD if results outside of parameters.

select "Yes" or "No"

Assess knowledge of prescribed diet, medications

select "Yes" or "No"

Assess compliance and ability to perform HEP

select "Yes" or "No"

Supervise HHA

select "Yes" or "No"

Assess patient ability to properly assess foot/skin integrity/status

select "Yes" or "No"

Assess patient knowledge of s/s disease exacerbation, appropriate interventions, prevention measures

select "Yes" or "No"

Initiate DC plan, review, complete, and have patient sign Notice of Medicare Non-coverage Notice (if applicable)

select "Yes" or "No"

Assess if Telehealth calls were initiated; assess for any issues/concerns to be addressed

select "Yes" or "No"

Finished

Please sign here! Go to Visit 2