EHR - Restricted Health Condition Care Plan

Resident Information

First Name

Last Name

Date of Birth

Admission Date

Room Number

Care Plan Author*

Restricted Health Condition Identification

Identified Restricted Health Condition(s)*

Diabetes Heart Disease COPD/Respiratory Disease Renal Disease Seizure Disorder Mental Health Condition Infection Control Requirements Other

Date of Condition Identification

Physician/Healthcare Provider

Last Medical Review Date

Next Scheduled Review Date

Care Plan Goals & Interventions

Primary Care Goals*

Planned Interventions & Services*

Monitoring Requirements*

Medication Management Plan

Dietary Modifications & Restrictions

Activity Restrictions or Modifications

Emergency Response Plan

Signs & Symptoms Requiring Immediate Attention*

Emergency Response Protocol*

Emergency Contact Information

Hospital Preference

Staff Training & Communication

Required Staff Training

Communication Requirements

Documentation Requirements

Ongoing Evaluation & Plan Updates

Progress Toward Goals

Changes to Condition Status

Plan Modifications Required

Additional Resources Needed

Mobility Assessment

Ambulation Status

Independent Uses Cane Uses Walker Wheelchair Bound Bedbound

Fall Risk Assessment

Low Risk Moderate Risk High Risk

Communication

Speech/Language

Clear Impaired Non-verbal

Hearing

Adequate Impaired Uses Hearing Aid

Vision

Adequate Impaired Uses Glasses

Medication Management

Medication Self-Administration

Independent Requires Supervision Full Staff Administration

Pain Management

Pain Assessment

No Pain Mild Pain Moderate Pain Severe Pain

Skin Integrity

Overall Skin Condition

Intact At Risk Impaired

Pressure Ulcer/Wound Presence

None Stage 1 Stage 2 Stage 3 Stage 4

Sleep Patterns

Sleep Quality

Good/Restful Fair Disturbed Insomnia

Sleep Aid Requirements

None Required Environmental Adjustments Medication

Respiratory Status

Breathing Pattern

Normal Labored Shortness of Breath Requires Oxygen

Cough/Secretions

None Occasional Productive Cough Chronic

Activities & Recreation

Activity Participation

Active Participation Selective Participation Minimal Participation Refuses Participation

Activity Preferences

Group Activities Individual Activities Physical Exercise Cognitive Activities Music/Arts

Family & Social Support

Family Involvement

Frequent Visits Regular Visits Occasional Visits Minimal/No Contact

Support System Adequacy

Strong Support Adequate Support Limited Support No Support

Safety & Environment

Safety Awareness

Appropriate Impaired Unaware of Risks

Environmental Adaptations Required

Bed Alarm Chair Alarm Bed Rails Night Lighting None Required

Special Treatments & Services

Current Therapy Services

Physical Therapy Occupational Therapy Speech Therapy None

Special Treatments

Wound Care IV Therapy Dialysis Tube Feeding None