Intermediate Core Team Documents

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DISTRICT NURSING Core Documents

Environmental Risk Assessment (ref.002)

First Assessment Decision Form (ref.001)

Telephone Log (ref.054)

Scheduling Sheet (ref.217)

Full Assessment Folder (with plastic folder) (ref.003)

Full Assessment (without plastic folder) (ref.003a)

Two Week Document (ref.004)

Single Visit Document (ref.167)

Ambulant Patient Clinic Letter (ref.200)

Ambulant Patient Document (ref.201)

CM/VW DNAR Supportive Care Document (ref.046)

Record of Care Additioanl Sheets (ref.055)

Additional Signature Sheet (ref.080)

Consent Form 3 and 3 (Additional Sheet) (ref.164)

Consent Form 4 including Mental Capacity Assessment (ref.165)

My Medication Record (ref.005)

Verification of Death (ref.058)

Additional Waterlow (ref.010)

Additional Mobility Assessment (ref.053)

6 CIT Cognitive Impairment Test (ref.041)

Mattress Audit Tool. (ref.049)

Pain Assessment Tool (ref.052)

Alcohol and Smoking CQUIN (ref.213)

Medicines Administration Record (MARs) (ref.205)

Falls Documentation

Fall and Bone Health Risk Assessment. (ref.081)

Post Fall Protocol Record.(ref.85)

Bed Rail Assessment Sheet.(ref.086)

Falls Diary Sheets.(ref.082)

Referral Forms

Community Nursing Bladder and Bowel Dysfunction Assessment (ref.183)

Tissue Viability Nurse Referral Form (ref.042)

Intermediate Care Referral Form (ref.083)

Charts

Blood Glucose Monitoring Table. (ref.006)

Bowel Habit Recording Chart. (ref.007)

Weight Monitoring Chart. (ref.008)

Nutrition and Fluid Chart (ref.009)

Haematology/Biochemistry/Results Action Sheet (ref.012)

Catheter Change History Sheet. (ref.013)

Prescribed Insulin Chart (ref.175)

District Nursing Core Care Plans

Tinzaparin. (ref.011)

Meeting Nutritional Needs. (ref.015)

Meeting Hydration Needs. (ref.016)

Low Risk of Malnutrition. (ref.017)

Medium Risk of Malnutrition. (ref.018)

High Risk of Malnutrition. (ref.019)

Nausea and/or Vomiting. (ref.20)

Breathing Problems. (ref.21)

Sight and/or Hearing Problems. (ref.022)

Instillation of Eye Drops. (ref.024)

Maintaining Body Temperature. (ref.025)

Constipation. (ref.026)

Meeting Personal Hygiene Needs (ref.027)

Mobility Problems. (ref.028)

Psychological Problems. (ref.029)

Risk of Developing DVT. (ref.030)

Phlebotomy. (ref.031)

INR Phlebotomy. (ref.032)

B12 Injection. (ref.033)

Insulin Injection. (ref.034)

Catheter Care. (ref.035)

COPD. (ref.037)

Heart Failure. (ref.038)

Pain Management. (ref.039)

Anti-embolic stockings. (ref.047)

Risk of Skin Breakdown (ref.203)

Blank Care Plan. (ref.048)

Tissue Viability and Wound Care Documents

Integrated Care Pathway for the Management and Treatment of Leg Ulcers (ref.056)

Pressure Ulcer Assessment (ref.044)

Wound Assessment and Care Plan (ref.045)

Wound Clock (ref.057)

Repositioning Chart (ref.091)

Addition Photography and template sheet (ref.212)

Additional Dressing Plan (ref.214)

Community Matron or Virtual Ward

Physical Assessment P12345678 (ref.211)

Observation Record (ref.176)

Identified Health and Social Care Needs (ref.210)

CM/VW Physical Assessment Plan (ref.209)

Syringe Driver Documentation

Syring Driver Booklet (Green) (ref.089)

Prescription for Bolus Injection or Rescue Dose Medication by GP Independent Prescriber (ref.087)

Prescription Sheet for GP Independent Prescriber (ref.090)

Stock Record Controlled Drugs (Green) (ref.088)

Intermediate Care Team

ICT 6 Week Booklet (ref.154)

ICT Goal Planning (ref.155)

ICT Treatment Plan (ref.156)

ICT Daily Recording Chart (SOAP Notes) (ref.157)

ICT Physiotherapy Assessment (ref.135)

ICT Lindop Rarkinson Mobility Assessment (ref.064)

ICT OT Dyspraxia Assessment. (ref.065)

ICT Upper Limb functional Assessment. (ref.066)

ICT OT Initial Interview. (ref.067)

ICT Perceptual Screen OT Assessment. (ref.068)

ICT OT Assessment of Activities of Daily Living (ref.070)

ICT Respiratory Assessment (ref.071)

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