island HOME CARE AGENCY inc.

INDIVIDUALIZED PLAN OF CARE Patient: _________________________________ Diagnosis: __________________________________PATIENT ID #_______ ____ Professional Signature: ___________________________________________________________________________ DATE PROBLEM

Knowledge Deficit related to:

PLAN/INTERVENTION EXPECTED OUTCOME/ GOALS AND TIMEFRAME

DATE RESOLVED

a) Signs & Symptoms of infection

Instruct on reporting to MD any redness, swelling, pain and/or temp. greater than 100.5

Patient/Caregiver verbalizes understanding of Signs & Symptoms of infection

b) Disease Process Instruct on ________________________ Disease process

Patient/Caregiver verbalizes understanding of disease process

c) Medication: action/side effects/dosing

Instruct on schedule to follow, end date, Lab Follow-up, precautions and side effects to report to MD

Patient/Caregiver verbalizes understanding of medication regime and remains compliant as ordered

d) Treatment Regime Instruct on : (describe treatment in narrative space below, i.e wound care/colostomy care/diabetic teach)

Patient/Caregiver returns demonstration of treatment(s)

Narrative:

mis/ncp generic.doc rev 8/05/dl