Interdisciplinary Comprehensive Assessment and Plan of

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					                                           Interdisciplinary Comprehensive Assessment and Plan of Care

PATIENT NAME: ____________________________ PATIENT ID#: ______________ DOB:______________ MD: _______________

NEPHROLOGIST: ___________________________________                                 ALLERGIES: _______________________________________

ASSESSMENT – Date: _______________________                              Plan of Care must be completed within 15 days of Re-Assessment

□ Initial (all patients* within 30 days)     □ 90 Day (patient new to dialysis or transfer in) □ Monthly (unstable)          □ Annual (stable)
* For patients who are not new to dialysis, and are transferring into the facility accompanied by an assessment/plan of care from the transferring
facility, a new assessment is required within 3 months of the admission

                                                   COMPLETE FOR INITIAL ASSESSMENT ONLY
                                                                (Complete by RN during orientation)
Date of First Dialysis: ____________________________________                      Medical History
        Location: ___________________________________________                     (check all that apply):
Date of First Dialysis in this Facility___________________________                 Congestive heart failure             GI Bleed _______________
Cause of Renal Disease:_____________________________________                       Ischemic heart disease               COPD
Level of Education Completed: ________________________________                     Myocardial infarction                Cancer – type: ___________
Literacy Level: _____________________________________________                            date: _______________           Dyslipidemia
Primary Language: __________________________________________                       Other cardiac disease:               Toxic nephropathy
Interpreter needed?  Yes  No                                                    specify____________________            Alcohol dependence
                     If Yes, date scheduled ______________________                 Cerebrovascular Disease, CVA,        Drug dependence
Living Situation:  Lives Alone  Personal Care/Assisted Living                   TIA                                    Tobacco use
                   Nursing Home ____________________________                      Peripheral vascular disease          HIV
                   Lives with others __________________________                   History of hypertension              Asthma
Religious Preference: _______________________________________                      Amputation - site: ___________       Arthritis – type: __________
Marital Status:  Single  Married  Divorced  Widowed                            Diabetes, currently on insulin       Gout
                 Significant Other                                                Diabetes, on oral medications        Alzheimer’s
ADL :  Independent                                                                Diabetes, without medications        Dementia
       Receives assistance – where? ____________________________                  Diabetic retinopathy                 Depression
       Requires referral for assistance to: ________________________              Peripheral neuropathy                Other mental illness: _________
Ambulation:  Independent  Needs Assist  Walker/Cane                             Osteodystrophy                       Other: ____________________
               Wheelchair  Stretcher




Interdisciplinary Comprehensive Assessment and Plan of Care                                           Completed By: ____________________________________
6/22/2009                                                              1 of 16
                                      Interdisciplinary Comprehensive Assessment and Plan of Care

PATIENT NAME: ____________________________ PATIENT ID#: ______________ DOB:______________ MD: _______________

                                  COMPLETE EACH OF THE FOLLOWING PAGES FOR ALL ASSESSMENTS
If patient is unstable, indicate reason (choose all that apply):                    N/A for Initial Assessment
         Change in modality  Significant change in psychosocial needs (explain below)  Marked deterioration in health status (explain below)
         Inadequate dialysis, Unmanaged anemia, Poor nutritional status (concurrent)  Extended or frequent hospitalization (explain below)
         Other Explanation: _______________________________________________________________________________________________
                                                                 DIALYSIS ORDERS
Hemodialysis orders:  Check if applicable                                      Peritoneal Dialysis orders:  Check if applicable  CAPD     CCPD
Duration: _____ hours _____ times per week          EDW: ________ kg            # of Exchanges: _____ Exchange Vol: ______ Total Vol: ______
Dialyzer: ____________________________                                          Midday Exchange:  Yes  No
Needle Gauge (if applicable):  15  16  17  Other:__________________         Dwell Time: _______________________
BFR: ______ cc/min UFR: ______ cc/ min                                          Last Fill: __________________________
UF profile: _______________               Na profile: _______________           Solution:
Dialysate: _________________________________________________                    ___________________________________________________
Na: _____ Ca: _____ K: _____ Bicarb: _____ Other: ______                        Heparin: ___________________         Insulin: ____________________
                                                                                Other: ___________________________________________________
                                                               CURRENT HEALTH STATUS
                                                                  (Complete by RN during orientation)
How does the patient rate his/her health status? Good  Fair  Poor                  Gastrointestinal:  No issues identified Constipation  Diarrhea
Level of Consciousness:  Alert  Oriented x 3  Disoriented                                Nausea  Vomiting  Anorexia  Distention  Pain
                         Responsive  Confused                                              Incontinent
    Explain: _________________________________________                                      Other ________________________________________________________
Vision:  Normal Corrective Lenses  Impaired(explain): ___________________          Genitourinary: Urine output:  > 1 cup/day  < 1 cup/day  none
Hearing:  Normal Hearing Aid  Impaired (explain): ______________________                  Incontinent  Pain  Other ______________________________________
Speech:  Normal  Impaired (explain): __________________________________             Extremities:  Edema – Location: _____________________________________
Wears Dentures:  N/A  Upper               Lower      Both                               Weakness  Tremors  Pain  Paralysis  Numbness/Tingling
                                                                                            Other: _______________________________________________________
Activity Level:  Sedentary  Mild  Moderate  Active
           Recent Change in Activity Level?  Yes  No
                                                                                      Skin:  Warm and dry  Wound-describe: _______________________________
                                                                                             Pale/redness/rash/bruising – Location ______________________________
Cardiovascular: Heart Rate: _______ Rhythm:  Regular  Irregular
      Chest Pain  Other: _____________________________
                                                                                      Previous Transplant  No  Yes
                                                                                      If Yes - Type:_________________________________ Date:__________________
Fluid Status: Edema (describe) ________________  Neck vein distention               Where? ____________________________________________________________
       Dry mouth  SOB  dizziness  Lack of skin turgor
     Explain: ____________________________________________
                                                                                      Comments:
Respiratory: Lungs:  Clear  Rales  Rhonchi  Wheezes                               _______________________________________________________
             Dyspnea  Cyanosis  SOB  Cough
     Does patient use oxygen?  Yes  No

Serum K level/date: _________________ Hemoglobin/date: _____________
INITIAL ORDERS ADJUSTED?  Yes  No If yes, explain:_________________________________________________________________________________________
Interdisciplinary Comprehensive Assessment and Plan of Care                                             Completed By: ____________________________________
6/22/2009                                                           2 of 16
                                                  Interdisciplinary Comprehensive Assessment and Plan of Care

PATIENT NAME: ____________________________ PATIENT ID#: ______________ DOB:______________ MD: _______________
TREATMENT ADHERENCE:                                                    N/A for Initial Assessment
          Knowledge:                     good               fair            poor        Acceptance:                   good          fair           poor
          Medications:                   good               fair            poor        Support:                      good          fair           poor
          Dietary Compliance:            good               fair            poor        Treatment Schedule:           good          fair           poor
(Responses of fair and poor must be addressed in the appropriate area of the plan of care)

MEDICATIONS:
     Home medication review completed:             Yes  No           With whom?  Patient  Significant other  Professional caregiver
                                                            If no, date to be completed: _________________________
      Does patient demonstrate understanding of indications, dosing and side effects?  Yes  No (If no, address in education plan of care)
      Issues identified with home medications:     Yes  No
              If yes, explain:________________________________________________________________________________________________
MODALITY ASSESSMENT (RN)                                                    MODALITY PLAN OF CARE
Current Modality:  Incenter Hemo                  Peritoneal              Goal: Patient understands treatment modality options and
                               Home Hemo
                                                                                                   has chosen modality
Did your nephrologist or dialysis team provide information about                                   Goal Met:  yes  no           If no, state reason:
modality choices to you?          yes  no                                                        _________________________________________________________
Do you understand your choices for treatment options?  yes  no                                   Action:  Continue current modality  Provide self cannulation training
                                                                                                            Provide machine set-up training  Other: __________________
Is patient a candidate for home dialysis?  yes  no
  If no please explain: ________________________________________                                   _____________________________________________________________
If yes, is patient interested in home dialysis?  yes  no
Is patient interested in any of the following Self Care opportunities?                             Target Date: _____________               Ongoing
          Self Cannulation        Setting up machine          Other: _________________
Patient’s treatment choice (if different from current modality):
         Hemodialysis:                       Incenter      Home                                 Goal: Patient is a suitable candidate for home treatment, is
         Peritoneal Dialysis:                CAPD           CCPD                                interested and has been referred for home training
                                                                                                   Goal Met:  yes  no  n/a If no, state reason:
                                                                                                   _________________________________________________________
                                                                                                   Action:       Provide and review modality education
                                                                                                                 Coordinate referral for home training
                                                                                                                 Other (describe) ________________________________________
                                                                                                   Target Date:  ___________________                Ongoing

MODALITY COMMENTS: ________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________

Interdisciplinary Comprehensive Assessment and Plan of Care                                                         Completed By: ____________________________________
6/22/2009                                                                                3 of 16
                                      Interdisciplinary Comprehensive Assessment and Plan of Care

PATIENT NAME: ____________________________ PATIENT ID#: ______________ DOB:______________ MD: _______________
TRANSPLANT STATUS ASSESSMENT (RN)                                          TRANSPLANT STATUS PLAN OF CARE
Did a member of the interdisciplinary team discuss transplant with you?    Goal: Patient educated regarding transplant option
 yes  no                                                                 Goal Met:  yes  no If no, state reason:
        Patient is not a suitable candidate for transplant at this time   _________________________________________________________
               Reason documented in medical record                        Action: Communicate with: ___________________________________
        Referred for transplant and/or in the process of evaluation       Target Date:  ___________________  Ongoing (at least annually)
        Patient active on transplant list
              Where? ________________________________________              Goal: Qualified candidate and active on transplant list
        Patient not interested in transplant at this time                 Goal Met:  yes  no  N/A             If N/A or no, state reason:
                                                                           _________________________________________________________
TRANSPLANT STATUS COMMENTS:                                                Action:       Coordinate referral to: ___________________________________
___________________________________________________________                              Provide information / referral when amenable
                                                                                         Other (describe) ________________________________________
                                                                           Target Date:  ___________________               Ongoing


IMMUNE STATUS ASSESSMENT (RN)                                              IMMUNE STATUS PLAN OF CARE
HBsAg:    __________   Result date:                ______________          Goal: Patient Offered Hepatitis B Vaccination if susceptible
HBsAb:    __________   Result date:                ______________          Goal Met:  yes  no If no, state reason:
HBcAb:    __________   Result date:                ______________          _________________________________________________________
Anti HCV: __________   Result date:                ______________          Action: Received series   Receiving 3 dose series  Refuses
                                                                                   Needs booster        Contraindicated
Has patient received Hepatitis B Series?      yes  no                    Target Date:  ___________________  Ongoing (at least annually)
Is patient susceptible (HBsAb < 10)?          yes  no
                                                                           Goal: Patient offered Influenza/Pneumonia Vaccination
History of Influenza Vaccine:     yes  no Date: ___________              Goal Met:  yes  no    If no, state reason:
History of Pneumonia Vaccine:     yes  no Date: ___________              _________________________________________________________
TB testing or Chest X-Ray:        yes  no Date: ___________              Action:  Offer vaccine  Educate patient/caregiver
       Results: _____________________________________________              Target Date:  ___________________  Ongoing

IMMUNE STATUS COMMENTS:                                     Goal: Patient has been screened for TB and results are in
___________________________________________________________ medical record
___________________________________________________________ Goal Met:  yes  no If no, state reason:
                                                            _________________________________________________________
                                                            Action:  Obtain order for PPD  Refer for CXR per MD order
                                                            Target Date:  ___________________  Ongoing

Interdisciplinary Comprehensive Assessment and Plan of Care                                 Completed By: ____________________________________
6/22/2009                                                        4 of 16
                                           Interdisciplinary Comprehensive Assessment and Plan of Care

PATIENT NAME: ____________________________ PATIENT ID#: ______________ DOB:______________ MD: _______________

ACCESS ASSESSMENT (RN)                                                             ACCESS PLAN OF CARE
Hemo Access: (if applicable)                                                       Goal: AVF as primary access for hemodialysis patients
Type and Location (include all accesses):                                          Goal Met:  yes  no If no, state reason:
 AVF                             Left                   Upper Arm               _________________________________________________________
 AVG                             Right                  Lower arm
                                                          Leg                     Action:       Vascular Surgeon referral
                                                                                                 Continue to monitor
 Catheter                           Left                  IJ                                  AVF in place - maturing
     Temporary <90 days             Right                 SC                                  Educate patient/caregiver re: importance of AVF as primary access
     Temporary > 90 days                                   Femoral                             Co morbid condition:______________________________
     Permanent (chronic)                                   Other: ____________                 Other (describe): _______________________________________
If catheter >90 days or permanent, reason: ____________________________________    Target Date:  ___________________               Ongoing

If more than one access, indicate which is primary: _________________              Goal: Access infection free Goal Met:  yes  no
If AVF is not primary access, has patient been referred for vein                   If no, state reason: ___________________________________________
mapping?        yes Date of referral: ______________                              Action:           Continue to monitor
                         Site: ___________________                                               Patient / caregiver education regarding care of access
                 no     Reason: __________________________________________                      Referral for AVF if catheter being used
                                                                                                 Antibiotics as prescribed
Hemo access problems (for both primary and secondary access - check                              Other (describe): _______________________________________
all that apply):                                                                   Target Date:  ___________________                 Ongoing

         Pain                              Frequent infiltrations
         Prolonged bleeding                Infection
                                                                                   Goal: Prescribed BFR maintained for hemodialysis patients
         Increased venous pressure         Poor blood flow                       Goal Met:  yes  no If no, state reason:
          Average VP: __________             Prescribed:_______ Actual: _______    _________________________________________________________
         Decreased arterial pressure       Aneurysm                              Action:       Continue to monitor  Obtain Access Flow Study
          Average AP: __________            Recirculation                                       Appointment made for access evaluation or revision
         Clotted                           Slow to mature                                      Referral for AVF if catheter being used
         Difficulty with cannulation       Other _________________________                     Other (describe): ______________________________________
                                                                                   Target Date:  ___________________                 Ongoing
If AVF is not primary access or problems are identified, has patient been
referred to a vascular surgeon?                                                    Goal: Stable AP or VP maintained for hemodialysis patients
                 yes    Date of referral: ______________
                         Surgeon: ___________________
                                                                                   Goal Met:  yes  no If no, state reason:
                 no     Reason: __________________________________________        _________________________________________________________
                                                                                   Action:       Continue to monitor   Obtain Access Flow Study
                                                                                                 Appointment made for access evaluation or revision
                                                                                                 Referral for AVF if catheter being used
                                                                                                 Other (describe): ______________________________________
                                                                                   Target Date:  ___________________               Ongoing
Interdisciplinary Comprehensive Assessment and Plan of Care                                       Completed By: ____________________________________
6/22/2009                                                               5 of 16
                                      Interdisciplinary Comprehensive Assessment and Plan of Care

PATIENT NAME: ____________________________ PATIENT ID#: ______________ DOB:______________ MD: _______________
(access assessment continued)                           (access plan of care continued)
Peritoneal Access: (if applicable)                      Goal: State goal for access problem noted on assessment
Is there an access for hemo if needed?        yes  no (describe):
Peritoneal access problems (check all that apply):      _________________________________________________________
        None identified       Pain
                                                                         Goal Met:  yes  no If no, state reason:
        Exit site infection   Peritonitis
                                                                         _________________________________________________________
        Flow problems         Tunnel infection
        Pressure                                                        Action:       Continue to monitor   Obtain Access Flow Study
                                                                                       Appointment made for access evaluation or revision
        Other
                                                                                       Referral for AVF if catheter being used
_______________________________________________________                                Other (describe): ______________________________________
                                                                         Target Date:  ___________________                Ongoing

ACCESS COMMENTS: __________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
EDUCATION AND TRAINING ASSESSMENT                            EDUCATION AND TRAINING PLAN OF CARE
(Complete during orientation - RN)
Patient/family/caregiver has been educated and demonstrates              Goal: Patient/family/caregiver has been educated and
understanding of each of the following (documentation in medical         demonstrates understanding of each of the areas identified,
record):
                                                                         with documentation in medical record. (Goal is not met if no
Cause of Renal Failure       yes  no Transplantation  yes  no
                                                                         answered to any question in assessment section.)
Dialysis Process             yes  no Rehabilitation  yes  no
                                                                         Goal Met:  yes  no If no, state reason:
Dialysis Management          yes  no Medications         yes  no
                                                                         _________________________________________________________
Infection Prevention         yes  no Access Care         yes  no
                                                                         Action:        Continue to monitor  Provide education
Personal Care                yes  no Quality of Life  yes  no                       Reinforce education Other(describe)__________________
Home Dialysis/Self Care  yes  no                                                                            ______________________________
                                                                                                              ______________________________
                                                                         Target Date:  ___________________          Ongoing

EDUCATION AND TRAINING COMMENTS: ______________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________




Interdisciplinary Comprehensive Assessment and Plan of Care                               Completed By: ____________________________________
6/22/2009                                                      6 of 16
                                         Interdisciplinary Comprehensive Assessment and Plan of Care

PATIENT NAME: ____________________________ PATIENT ID#: ______________ DOB:______________ MD: _______________


DOSE OF DIALYSIS ASSESSMENT (RN/RD)                                                 DOSE OF DIALYSIS PLAN OF CARE
Kt/V: ____________________ Result date:_______________                              Goal: HD - Kt/V >1.2 (URR > 65%) or                          PD - Kt/V >1.7
                                                                                    Goal Met:  yes  no
Measures to improve adequacy (if warranted, check all that apply):                        If goal not met, reason (check all that apply)
          Increase in dialyzer size         Increase of treatment time                              Inadequate BFR / DFR               Inadequate dialyzer
          Evaluation or revision of access  Heparin dose re-evaluated                               Inadequate treatment time          Inadequate heparinization
          Inadequate heparinization         Increase in prescribed BFR and DFR                      Poorly functioning access          Catheter as primary access (HD)
          Other (describe): _____________________________________________                            Noncompliance with exchanges (PD)
                                                                                                      Other (describe)________________________________________
PD – PET testing done  yes  no                                                    Action:  Continue current orders              Increase BFR to __________
                                                                                            Increase time to __________           Change dialyzer to _________
                                                                                            Increase Heparin dose to _____        Evaluate access function
Average interdialytic weight gain:_________ kg                                              Adjust prescribed DFR to _____        Evaluate for fibrin/bloody effluent
                                                                                            Educate patient re: importance of compliance with treatment time
Does patient reach target weight at end of treatment?  yes  no                             Increase # PD exchanges              Increase volume PD exchanges
                                                                                             Change % dextrose PD exchanges  Other (describe) _______________
                                                                                                                                    _____________________________
Is IDWG > 1.5 kg.day?  yes  no                                                                                                   _____________________________
                                                                                    Target Date:  ___________________              Ongoing
Is BP ≤ 130 systolic post treatment?  yes  no
                                                                                    Goal: Patient is able to reach target weight post treatment
Does patient experience any of the following during treatment:
    dizziness                hypertension                                         without adverse intradialytic symptoms
    headache                hypotension                                           Goal Met:  yes  no
                                                                                     If goal not met, reason (check all that apply):
    nausea/vomiting          pain                                                    EDW too high                              Noncompliance with sodium intake
    cramping                pressure                                                 EDW too low                               Medication - inadequate response
                                                                                       Noncompliance with fluid intake            Does not understand diet
                                                                                       Noncompliance with medications             Other: _________________________
                                                                                       Requires increased treatment time/UF         ______________________________
                                                                                       Noncompliance with exchanges (PD)            ______________________________
                                                                                    Action:  Continue current orders       Education re: medications
                                                                                            Increase EDW                   Increase dialysis time/schedule extra tx
                                                                                            Decrease EDW                    Reevaluate medications
                                                                                            UF profiling                   Education re: diet/fluids
                                                                                            Na modeling                     Other: ____________________________
                                                                                                                    _________________________
                                                                                    Target Date:  ___________________      Ongoing
DOSE OF DIALYSIS COMMENTS:
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Interdisciplinary Comprehensive Assessment and Plan of Care                                             Completed By: ____________________________________
6/22/2009                                                                 7 of 16
                                      Interdisciplinary Comprehensive Assessment and Plan of Care

PATIENT NAME: ____________________________ PATIENT ID#: ______________ DOB:______________ MD: _______________


ANEMIA ASSESSMENT (RN)                                                  ANEMIA PLAN OF CARE
Hgb: __________________               Result date:_______________       Goals:    (check if goal achieved)
Ferritin: _______________             Result date:_______________          Hgb 10.0 – 12.0            TSat 20 - 50%            Ferritin 200 - 800
TSat: _________________               Result date:_______________       All Goals Met:  yes  no
CRP: _________________                Result date:_______________             If goal(s) not met check reason (check all that apply)
Retic. Count: ____________            Result date:_______________                        Infection               Iron deficiency
Is patient receiving EPO?       yes  no                                                Potential blood loss    Recent hospitalization/surgery
        Dose/Route/Frequency: _____________________________                              New to dialysis         Co morbid condition
Is patient receiving Iron?      yes  no                                                Other (describe)________________________________________
        Dose/Route/Frequency: _____________________________             Action:  Continue current EPO dose                Increase EPO to ___________
                                                                                 Hold EPO                                 Decrease EPO to __________
Has patient received recent blood transfusion?       yes  no                   Initiate iron therapy                   Treat source of bleeding
        Amount: _________________            Date:______________                 Evaluate possible EPO resistance         Other (describe) ___________
Evidence of active infection  yes  no                                          Treat infection
        Site: _____________________________________________
Occult Blood test        yes  no                                      Target Date:  ___________________                Ongoing
        Results: __________________          Date:______________
                                                                        Goal: Completed training for home ESA administration (if
                                                                        applicable)
                                                                        Goal Met:  yes  no  n/a             If no, state reason:
                                                                        ________________________________________________________
                                                                        Action:       Provide training for home ESA administration
                                                                                         Other (describe): _______________________________________

                                                                        Target Date:  ___________________                  Ongoing


ANEMIA COMMENTS: __________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________




Interdisciplinary Comprehensive Assessment and Plan of Care                                Completed By: ____________________________________
6/22/2009                                                     8 of 16
                                      Interdisciplinary Comprehensive Assessment and Plan of Care

PATIENT NAME: ____________________________ PATIENT ID#: ______________ DOB:______________ MD: _______________

CA/PO4 MANAGEMENT ASSESSMENT (RD)                                          CA/PO4 MANAGEMENT PLAN OF CARE
Ca++: _______________                Result date:_______________           Goals: (check if goal achieved)
CaPO4 Product: _________             Result date:_______________                 CaPO4 Product < 55                     Calcium 8.5 – 10.2
PO4: _____________                   Result date:_______________
                                                                                 iPTH 150 – 300                         Phosphorus 3.5 – 5.5
iPTH: _____________                  Result date:_______________
                                                                           All Goals Met:  yes  no
Corrected Ca++: _________________
                                                                                 If goal(s) not met check reason (check all that apply)
Is patient receiving Vitamin D analog?       yes  no                                      Noncompliance with diet          Noncompliance with binders
         Zemplar      Hectoral      Calcitriol                                           Inadequate dose of binders
        Dose/Route/Frequency: _____________________________                                 Inadequate resources to obtain medications
Is patient receiving Sensipar?           yes  no                                          Other (describe)________________________________________
        Dose/Frequency: __________________________________
                                                                           Action:  Continue current treatment                 Increase Vit D to ___________
Are binders prescribed?        yes  no                                             Hold Vit D                                Decrease Vit D to __________
        Phoslo        Renagel        Renvela                                      Adjust binders
        Fosrenol      Tums                                                         Evaluate dietary intake – encourage compliance
       Dose/Frequency: __________________________________                            Investigate resources to obtain medications
                                                                                     Other (describe) _____________________________________________

If binder prescribed, is patient compliant with dose?     yes  no
                                                                           Target Date:  ___________________  Ongoing

CALCIUM PHOSPHORUS MANAGEMENT COMMENTS: ___________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________




Interdisciplinary Comprehensive Assessment and Plan of Care                                   Completed By: ____________________________________
6/22/2009                                                        9 of 16
                                      Interdisciplinary Comprehensive Assessment and Plan of Care

PATIENT NAME: ____________________________ PATIENT ID#: ______________ DOB:______________ MD: _______________

NUTRITIONAL STATUS ASSESSMENT (RD)                                             NUTRITIONAL STATUS PLAN OF CARE
Albumin: _______________    Result date:_______________                        Goals:    (check if goal achieved)
 +
K : _________               Result date:_______________                          Albumin > 4.0               Potassium 3.5 – 5.5                 Hgb A1C < 7.0
HgbA1C: _____________       Result date:_______________
Cholesterol: _____________  Result date:_______________                        All Goals Met:  yes  no
Triglycerides: ____________ Result date:_______________                              If goal(s) not met check reason (check all that apply)
Glucose: ____________       Result date:_______________                                          Noncompliance with diet          Poor appetite
BMI:____________            Result date:_______________                                          Difficulty chewing               Difficulty swallowing
                                                                                                 Inadequate dialysis              Knowledge deficit (nutritional)
                                                                                                 Inadequate resources to obtain medications
Current Appetite:       Good          Fair          Poor
                                                                                                 Noncompliance with medications (specify)
                        Improving     Declining     No Change                                _______________________________________________________
Dentition:     Own teeth       Good           Fair         Poor                               Inadequate dose of medication (specify)
               Dentures        Upper          Lower        Partial                           _______________________________________________________
Is patient Diabetic?  yes  no                                                                  Other (describe)________________________________________
        If yes, how is diabetes controlled?                                    Action:
                Diet          Oral Medication        Insulin                           Continue with present orders               Appetite stimulant
       If yes, does patient monitor blood sugar at home?  yes  no                       Investigate resources to obtain meds       IDPN
Any complaints of (check all that apply):                                                 Evaluate insulin doses                     Evaluate dialysis prescription
                                                                                          Investigate resources to obtain medications
    constipation         gas                                                            Dietary counseling for patient, family, and/or caregiver
    diarrhea            difficulty chewing                                              Assist with weight loss recommendations/program
    nausea              difficulty swallowing                                           Other (describe) _____________________________________________
    vomiting            frequent indigestion                                             __________________________________________________________
    lack of appetite                                                                      __________________________________________________________
                                                                                           __________________________________________________________
Any history of (check all that apply):
    GERD                  Diverticulosis
    GI bleed              Peptic ulcer disease
    Crohn’s disease  Other: ____________________________
                                                                               Target Date:  ___________________                    Ongoing
    Gastroparesis
Caloric / Energy needs: ______________________________________
Protein needs: _____________________________________________

Has patient been educated about prescribed diet?       yes  no
Renal diet education completed:        yes  no      Date:____________
Diet education materials provided  yes  no          Date:____________
Does patient demonstrate understanding of diet?        yes  no
Is patient compliant with prescribed diet?             yes  no

Interdisciplinary Comprehensive Assessment and Plan of Care                                        Completed By: ____________________________________
6/22/2009                                                           10 of 16
                                      Interdisciplinary Comprehensive Assessment and Plan of Care

PATIENT NAME: ____________________________ PATIENT ID#: ______________ DOB:______________ MD: _______________
(nutrition status assessment continued)

If patient is a transplant candidate, is weight loss necessary to qualify?
                                                         yes  no
Meal pattern: Meals/day _________________
                  Snacks/day ________________
                  Meals away from home/week _____________________
Meal Preparation:  Self  Family member  Personal Care Assistant
                      Meals on Wheels________________meals/day
                      Other
Does patient use supplements?             yes  no Type: _____________
Does patient use vitamins/herbs?          yes  no Type: _____________
Weight History
        Height ___________               EDW ___________
        UBW ____________                 % UBW __________
        IBW _____________                % IBW __________
        ABW (if > 115% IBW) ______________________
Has patient’s weight decreased by >5% ?  yes  no

NUTRITION STATUS COMMENTS: ___________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________




Interdisciplinary Comprehensive Assessment and Plan of Care                       Completed By: ____________________________________
6/22/2009                                                          11 of 16
                                      Interdisciplinary Comprehensive Assessment and Plan of Care

PATIENT NAME: ____________________________ PATIENT ID#: ______________ DOB:______________ MD: _______________

PSYCHOSOCIAL STATUS ASSESSMENT (MSW)                                      PSYCHOSOCIAL STATUS PLAN OF CARE
Emotional Status:                                                         Goals:  (check if goal achieved)
                                                                             Adjusted to treatment Compliant with treatment
 Stable  Depression  Anxiety
                                                                             Behavior appropriate Adequate financial resources
 Behavioral Issues
 Other __________________________________________________                   Family supportive
_________________________________________________________                    KDQOL-36 completed at least annually
_________________________________________________________                    Patient specific goals (please describe below)
                                                                                 ______________________________________________________________
Is patient currently receiving counseling? ? Yes ? No                            ______________________________________________________________
                                                                                 ______________________________________________________________
    If yes, where? ___________________________________________
                                                                          All Goals Met:  yes  no If no, state reason:
    If no, is counseling indicated? ? Yes ? No
                                                                          _________________________________________________________
                                                                          Action:
Has KDQOL-36 Assessment been administered? ? Yes ? No                             Continue to monitor                      Referral for counseling
                                                                                  Education
                                                                                  Referral to community services (describe below)
                                                                                 _____________________________________________________________
                                                                                 _____________________________________________________________
                                                                                  Administer KDQOL-36
                                                                                  Other (describe) _____________________________________________
                                                                                 _____________________________________________________________
                                                                                 _____________________________________________________________
                                                                          Target Date:  ___________________                  Ongoing



SOCIAL SERVICES ISSUES                        Currently Have              Referral Needed                      Referral Complete/Date
Extra Help for Medicare D
State Kidney Disease Program
Food Stamps
Medical Assistance
Utility Assistance Program
Part B Premium Assistance
Financial Assistance Application
Other (describe)



Interdisciplinary Comprehensive Assessment and Plan of Care                                Completed By: ____________________________________
6/22/2009                                                      12 of 16
                                      Interdisciplinary Comprehensive Assessment and Plan of Care

PATIENT NAME: ____________________________ PATIENT ID#: ______________ DOB:______________ MD: _______________
(MSW)
TRANSPORTATION:
     Drives self                      Public / Taxi / Bus            Family / Friend            Insurance funded transportation
     Ambulance / Chair Car            Needs transportation           Other (describe): _________________________________________________
        Transportation Issues / Comments:_____________________________________________________________________________________
        _________________________________________________________________________________________________________________
ADVANCED DIRECTIVE:
    Does the patient have a signed advanced directive?                 yes  no       Information provided Date:__________
    If yes, is there a copy on file?                                   yes  no
    Is this a state mandated advanced directive?                       yes  no
    If no, does the patient want advanced directives?                  yes  no       Information provided Date:__________
DNR:
        Has patient chosen DNR status?        yes  no       If yes, is a copy on file?       yes  no
        Is a copy of the MD order on file?    yes  no
        DNR reviewed annually?                yes  no       If yes, are there any changes?  yes  no
        Funeral home identified               yes  no       Funeral home Contact Information:             _______________________________
                                                                                                            _______________________________
                                                                                                            _______________________________
POWER OF ATTORNEY:
    Medical    yes  no              If yes, who?____________________________________________________________________________
    Financial  yes  no              If yes, who?____________________________________________________________________________
LIVING WILL:
      Has patient executed a living will?     yes  no                   If yes, is a copy on file?    yes  no

PSYCHOSOCIAL STATUS COMMENTS: __________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________




Interdisciplinary Comprehensive Assessment and Plan of Care                                       Completed By: ____________________________________
6/22/2009                                                            13 of 16
                                       Interdisciplinary Comprehensive Assessment and Plan of Care

PATIENT NAME: ____________________________ PATIENT ID#: ______________ DOB:______________ MD: _______________

REHABILITATION STATUS ASSESSMENT (MSW)                                            REHABILITATION STATUS PLAN OF CARE
Employment Status:                                                                Goal: Describe patient specific goal:
        Unemployed            Student               Homemaker
        Employed Part Time    Employed Full Time    Retired – Age
                                                                                  ___________________________________________________
        Retired – Medical     Disabled                                          ___________________________________________________
If Unemployed:
        Desire to work/attend school?          yes  no                          Goal Met:  yes  no
        Physically able to work?               yes  no                          Action:
Has patient been informed of Vocational Rehabilitation Services?                          Continue to monitor                Assist with community referrals
         yes  no                                                                        Referral for vocational rehabilitation counseling
Patient’s goals (vocational, educational, personal):__________________                    Referral for physical rehabilitation
                                                                                          Other (describe) _____________________________________________
__________________________________________________________                               _____________________________________________________________
                                                                                         _____________________________________________________________
                                                                                  Target Date:  ___________________                   Ongoing

REHABILITATION STATUS COMMENTS:
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________

INSURANCE STATUS
Current Insurance Status: _______________________________
       ____________________________________________________
Have there been any changes since the last assessment?  yes  no
Medicare Part D?                                        yes  no
Prescription Assistance Program?                        yes  no

Insurance:
               1.) ___________________________________________                                           3.)_______________________________________
                       Active          Primary      Secondary                                         _____
                       Prescription    Pending                                                                  Active          Primary       Secondary
                                                                                                                  Prescription    Pending
               2.) ___________________________________________
                       Active          Primary      Secondary
                       Prescription    Pending

Is insurance adequate? Yes? ? No
                                                                                         Plan for Inadequate Insurance:
                                                                                         _______________________________
Interdisciplinary Comprehensive Assessment and Plan of Care                                         Completed By: ____________________________________
6/22/2009                                                              14 of 16
                                      Interdisciplinary Comprehensive Assessment and Plan of Care

PATIENT NAME: ____________________________ PATIENT ID#: ______________ DOB:______________ MD: _______________
                                                            _____________________________________________________
                                                            _____
                                                            _____________________________________________________
                                                            _____

PLAN OF CARE SIGNATURES / COMMENTS:
Physician’s Comments:
       _____________________________________________________________________________________________________
       _____________________________________________________________________________________________________
       _____________________________________________________________________________________________________
       MD’s Signature: _________________________________

RN’s Comments:
      _____________________________________________________________________________________________________
      _____________________________________________________________________________________________________
      _____________________________________________________________________________________________________
      RN’s Signature: __________________________________

Social Worker’s Comments:
       _____________________________________________________________________________________________________
       _____________________________________________________________________________________________________
       _____________________________________________________________________________________________________
       Social Worker’s Signature: __________________________

Dietitian’s Comments:
        _____________________________________________________________________________________________________
        _____________________________________________________________________________________________________
        _____________________________________________________________________________________________________
        Dietitian’s Signature: ______________________________

Plan of Care Meeting Date: _______________________________
        □ Patient Participated OR □ Reviewed with Patient by __________________________ (IDT Member) On:________________ (date)
        Patient’s Comments:
        _____________________________________________________________________________________________________
        _____________________________________________________________________________________________________
        _____________________________________________________________________________________________________

Interdisciplinary Comprehensive Assessment and Plan of Care                       Completed By: ____________________________________
6/22/2009                                                     15 of 16
                                      Interdisciplinary Comprehensive Assessment and Plan of Care

PATIENT NAME: ____________________________ PATIENT ID#: ______________ DOB:______________ MD: _______________
     Patient’s Signature: _______________________________                  Date:___________________________




Interdisciplinary Comprehensive Assessment and Plan of Care                       Completed By: ____________________________________
6/22/2009                                                     16 of 16