Social History Consults Treatments Sold home and moved into this Comprehensive care team facility 4 months ago Assisted living staff Husband died 4 weeks ago Race: Religion: Baptist Medication brought from home: All medications listed in Provider Orders Diagnostic Studies Activities of Daily Living Meals Lab RPR, TSH, CBC with Needs reminders. Aide Breakfast and dinner in the – community dining room differential, B12, folate, LFT comes 3x/week to help with May need to bring her to dining bathing. room and supervise. Has lost weight. Medical Reconciliation Form Source of medication list (check all that apply) patient medication list, patient/family recall, pharmacy, PCP list, previous discharge paperwork, MAR for facility Allergies: NKA Medication Name Dose Route Frequency Last Dose Continue/DC C DC Provider Signatures Date/Time Initial Provider Signature Nurse Signatures Date/Time Initial Nurse Signature Reviewed on Transfer by: Date: Reviewed on Discharge by: Date: Scan to Pharmacy Time: Date:
Social History Sold home and moved into this facility 4 months ago Husband died 4 weeks ago Race: Religion: Baptist Medication brought from home: All medications listed in Provider Orders Consults Comprehensive care team Assisted living staff Treatments Diagnostic Studies Lab – RPR, TSH, CBC with differential, B12, folate, LFT Activities of Daily Living Needs reminders. Aide comes 3x/week to help with bathing. Meals Breakfast and dinner in the community dining room May need to bring her to dining room and supervise. Has lost weight. Medical Reconciliation Form Source of medication list (check all that apply) patient medication list, patient/family recall, pharmacy, PCP list, previous discharge paperwork, MAR for facility Allergies: NKA Medication Name Dose Route Frequency Last Dose Continue/DC C DC Provider Signatures Date/Time Initial Provider Signature Nurse Signatures Date/Time Initial Nurse Signature Reviewed on Transfer by: Reviewed on Discharge by: Date: Date: Scan to Pharmacy Time: Date:
chartmaterialsforerthawilliams-simulation2.docx