Files > NUPA CARE PLANS

name
NUPA CARE PLANS
number
1927.4
location
^NUPA(1927.4,
description
These are the interdisciplinary care plans that are done by nurses or other medical personnel. Information is uploaded from the assessment_careplan GUI. Do not edit this file via Fileman.
Fields
#NameLocationTypeDetailsIndexDescription
.01date/time entered(+)0;1DATE-TIMEBThis is the DATE/TIME ENTERED from the last assessment or reassessment
1patient0;2POINTER2CThis is the PATIENT from the last assessment or reassessment
2entered by0;3POINTER200This is the ENTERED BY from the last assessment or reassessment
3guardian name0;4FREE TEXTThis is the patient's legal guardian.
4primary language0;5FREE TEXTThis is the patient's primary language.
4.5accomplish by this hosp15;0WORD-PROCESSING
5cultural practices0;6BOOLEAN1:YES
0:NO
These are any cultural practices that the patient may have that the nurse believes may affect care.
5.1cultural practices description2;0WORD-PROCESSINGThis is the CULTURAL PRACTICES DESCRIPTION from the last assessment or reassessment
6blood transfusion concerns0;7BOOLEAN1:YES
0:NO
Any blood tranfusion concerns that patient may have.
6.1blood transfusion description3;0WORD-PROCESSINGThis is the BLOOD TRANSFUSION DESCRIPTION from the last assessment or reassessment
7advance directive0;8BOOLEAN1:YES
0:NO
Does the patient have any advance directives?
7.1advance directive location4;0WORD-PROCESSINGThis is the ADVANCE DIRECTIVE LOCATION from the last assessment or reassessment
8special diet needs0;9BOOLEAN1:YES
0:NO
Does the patient have any special diet needs?
8.1special diet needs description5;0WORD-PROCESSINGThis is the SPECIAL DIET NEEDS DESCRIPTION from the last assessment or reassessment
10suspected victim of abuse/negl0;10BOOLEAN1:YES
0:NO
Does the nurse suspect that the patient is a victim of abuse or neglect?
11organ donor0;11BOOLEAN1:YES
0:NO
Is the patient an organ donor?
12allergy pointer1;0MULTIPLE1927.412List of the patients allergies as of the moment of the care plan.
13precautions0;14FREE TEXTMRSA precautions to take around this patient.
14level of understanding0;15POINTER1927.41The level of understanding that a patient has of the education they were just given on MRSA.
17precautions (flags)6;0MULTIPLE1927.417Any precauions or flags (local or national) as of the moment of the care plan.
18latest dnr note0;12POINTER8925Latest DNR note, if any, on file for this patient.
19ward0;13POINTER44Ward that the patient was on as of the moment of the care plan.
20oriented10;1FREE TEXTWas the patient oriented to his/her room as of the moment of the care plan.
21able to assess education10;2BOOLEAN1:YES
0:NO
Was the nurse able to assess the patient's level of education?
22learns best by10;3FREE TEXTHow does the patient learn best? Hearing, seeing, etc.
23education preferred10;4FREE TEXTWhat kind of education does the patient prefer? Computer based, group classes, etc.
24readiness to learn10;5POINTER1927.41What is the patient's readiness to learn? Ready to learn, not ready, sedated, etc.
25barriers to learning10;6FREE TEXTDoes the patient have any barriers to learning? None, mental status, hearing, etc.
25.1barriers to learning descrip11;0WORD-PROCESSINGThis is the BARRIERS TO LEARNING DESCRIP from the last assessment or reassessment
26knowledge of current illness10;7SET OF CODES0:NONE
1:LIMITED
2:EXTENSIVE
What is the patient's level of knowledge of his/her illness? None, limited, or extensive.
27educational info provided10;8FREE TEXTWas any educational information provided to the patient? BCMA, Managing Your Pain, etc.
30interventions20;0MULTIPLE1927.47Nursing Interventions provided to correct problems that a patient has.
31problems21;0MULTIPLE1927.431List of problems that a patient has.
32problem comments12;0WORD-PROCESSINGMedical comments on the patient's problems.
40disch to home wo add services30;1BOOLEAN1:YES
0:NO
Should the patient be discharged to his/her home without additional services?
41dp goals30;2FREE TEXTDoes the patient need assistance from a Discharge Planning nurse or a Social Worker?
41.1dp goals other 141;1FREE TEXTThe "Other 1" free text goal entered by the user.
41.2dp goals other 241;2FREE TEXTThe "Other 2" free text goal entered by the user.
41.3dp goals other 341;3FREE TEXTThe "Other 3" free text goal entered by the user.
42braden score30;3NUMERICThe patient's Braden Score as of the moment of the care plan.
42.5braden score date30;5DATE-TIMEDate that the Braden test was done.
43morse score30;4NUMERICThe patient's Morse Fall score as of the moment of the care plan.
43.5morse score date30;6DATE-TIMEDate that the Morse Fall test was done.
44family support involved in dp7;0WORD-PROCESSINGDoes the patient need family support in the planning of his/her discharge?
45dp observations/comments31;0WORD-PROCESSING
50general observations/comments13;0WORD-PROCESSINGGeneral comments on this care plan.
60problem evaluations8;0MULTIPLE1927.49Log of evaluations of the patient's problems.
61intervention evaluation9;0MULTIPLE1927.461Log of interventions to help the patient's problems.
70bed to chair14;1FREE TEXTThis is the BED TO CHAIR from the last assessment or reassessment
70.5bed to chair staff14;2NUMERICThis is the BED TO CHAIR STAFF from the last assessment or reassessment
71bed to stretcher14;3FREE TEXTThis is the BED TO STRETCHER from the last assessment or reassessment
71.5bed to stretcher staff14;4NUMERICThis is the BED TO STRETCHER STAFF from the last assessment or reassessment
72chair to stretcher14;5FREE TEXTThis is the CHAIR TO STRETCHER from the last assessment or reassessment
72.5chair to stretcher staff14;6NUMERICThis is the CHAIR TO STRETCHER STAFF from the last assessment or reassessment
73repos in bed14;7FREE TEXTThis is the REPOS IN BED from the last assessment or reassessment
73.5repos in bed staff14;8NUMERICThis is the REPOS IN BED STAFF from the last assessment or reassessment
74repos in chair14;9FREE TEXTThis is the REPOS IN CHAIR from the last assessment or reassessment
74.5repos in chair staff14;10NUMERICThis is the REPOS IN CHAIR STAFF from the last assessment or reassessment
75transfer from floor14;11FREE TEXTThis is the TRANSFER FROM FLOOR from the last assessment or reassessment
75.5transfer from floor staff14;12NUMERICThis is the TRANSFER FROM FLOOR STAFF from the last assessment or reassessment
76sling type14;13POINTER1927.41This is the SLING TYPE from the last assessment or reassessment
77sling size14;14POINTER1927.41This is the SLING SIZE from the last assessment or reassessment
100gen info done(+)100;1BOOLEAN1:YES
0:NO
Yes/No flag noting if the General Info tab has been completed.
102resp done(+)100;3BOOLEAN1:YES
0:NO
Yes/No flag noting if the Respiratory tab has been completed.
103cv done100;4BOOLEAN1:YES
0:NO
Yes/No flag noting if the CV tab has been completed.
104neuro done(+)100;5BOOLEAN1:YES
0:NO
Yes/No flag noting if the Neuro tab has been completed.
105gi done100;6BOOLEAN1:YES
0:NO
Yes/No flag noting if the GI tab has been completed.
106gu done(+)100;7BOOLEAN1:YES
0:NO
Yes/No flag noting if the GU tab has been completed.
107ms done(+)100;8BOOLEAN1:YES
0:NO
Yes/No flag noting if the Musculoskeletal tab has been completed.
108skin done(+)100;9BOOLEAN1:YES
0:NO
Yes/No flag noting if the Skin tab has been completed.
109ps done(+)100;10BOOLEAN1:YES
0:NO
Yes/No flag noting if the Psychosocial tab has been completed.
110mh done(+)100;11BOOLEAN1:YES
0:NO
Yes/No flag noting if the Mental Health tab has been completed.
111func done(+)100;12BOOLEAN1:YES
0:NO
Yes/No flag noting if the Functional tab has been completed.
112dp done(+)100;13BOOLEAN1:YES
0:NO
Yes/No flag noting if the Discharge Planning tab has been completed.
113rel practices for chaplain100;14BOOLEAN1:YES
0:NO
This is the REL PRACTICES FOR CHAPLAIN from the last assessment or reassessment
114immediate chaplain visit100;15BOOLEAN1:YES
0:NO
This is the IMMEDIATE CHAPLAIN VISIT from the last assessment or reassessment
114.1should clergy be notified100;22BOOLEAN1:YES
0:NO
This is the SHOULD CLERGY BE NOTIFIED from the last assessment or reassessment
115recv info on ad100;16BOOLEAN1:YES
0:NO
This is the RECV INFO ON AD from the last assessment or reassessment
116initiate or change ad100;17BOOLEAN1:YES
0:NO
This is the INITIATE OR CHANGE AD from the last assessment or reassessment
117test for mrsa brochure given100;18BOOLEAN1:YES
0:NO
This is the TEST FOR MRSA BROCHURE GIVEN from the last assessment or reassessment
117.1patient authorize nares100;19BOOLEAN1:YES
0:NO
This is the PATIENT AUTHORIZE NARES from the last assessment or reassessment
117.2nares preformed100;20BOOLEAN1:YES
0:NO
This is the NARES PREFORMED from the last assessment or reassessment
118infection control ed provided100;21BOOLEAN1:YES
0:NO
This is the INFECTION CONTROL ED PROVIDED from the last assessment or reassessment
120pain location 1101;1FREE TEXTThis is the PAIN LOCATION 1 from the last assessment or reassessment
121pain type 1101;2NUMERICThis is the PAIN TYPE 1 from the last assessment or reassessment
122onset of pain 1101;3FREE TEXTThis is the ONSET OF PAIN 1 from the last assessment or reassessment
123pain worse 1101;4FREE TEXTThis is the PAIN WORSE 1 from the last assessment or reassessment
124pain better 1101;5FREE TEXTThis is the PAIN BETTER 1 from the last assessment or reassessment
125areas of life 1101;6FREE TEXTThis is the AREAS OF LIFE 1 from the last assessment or reassessment
126pain goal 1101;7NUMERICThis is the PAIN GOAL 1 from the last assessment or reassessment
127other pain region 1127;0WORD-PROCESSING
130pain location 2102;1FREE TEXTThis is the PAIN LOCATION 2 from the last assessment or reassessment
131pain type 2102;2NUMERICThis is the PAIN TYPE 2 from the last assessment or reassessment
132onset of pain 2102;3FREE TEXTThis is the ONSET OF PAIN 2 from the last assessment or reassessment
133pain worse 2102;4FREE TEXTThis is the PAIN WORSE 2 from the last assessment or reassessment
134pain better 2102;5FREE TEXTThis is the PAIN BETTER 2 from the last assessment or reassessment
135areas of life 2102;6FREE TEXTThis is the AREAS OF LIFE 2 from the last assessment or reassessment
136pain goal 2102;7NUMERICThis is the PAIN GOAL 2 from the last assessment or reassessment
137other pain region 2137;0WORD-PROCESSING
140pain location 3103;1FREE TEXTThis is the PAIN LOCATION 3 from the last assessment or reassessment
141pain type 3103;2NUMERICThis is the PAIN TYPE 3 from the last assessment or reassessment
142onset of pain 3103;3FREE TEXTThis is the ONSET OF PAIN 3 from the last assessment or reassessment
143pain worse 3103;4FREE TEXTThis is the PAIN WORSE 3 from the last assessment or reassessment
144pain better 3103;5FREE TEXTThis is the PAIN BETTER 3 from the last assessment or reassessment
145areas of life 3103;6FREE TEXTThis is the AREAS OF LIFE 3 from the last assessment or reassessment
146pain goal 3103;7NUMERICThis is the PAIN GOAL 3 from the last assessment or reassessment
147other pain region 3147;0WORD-PROCESSING
150pain location 4104;1FREE TEXTThis is the PAIN LOCATION 4 from the last assessment or reassessment
151pain type 4104;2NUMERICThis is the PAIN TYPE 4 from the last assessment or reassessment
152onset of pain 4104;3FREE TEXTThis is the ONSET OF PAIN 4 from the last assessment or reassessment
153pain worse 4104;4FREE TEXTThis is the PAIN WORSE 4 from the last assessment or reassessment
154pain better 4104;5FREE TEXTThis is the PAIN BETTER 4 from the last assessment or reassessment
155areas of life 4104;6FREE TEXTThis is the AREAS OF LIFE 4 from the last assessment or reassessment
156pain goal 4104;7NUMERICThis is the PAIN GOAL 4 from the last assessment or reassessment
157other pain region 4157;0WORD-PROCESSING
160pain location 5105;1FREE TEXTThis is the PAIN LOCATION 5 from the last assessment or reassessment
161pain type 5105;2NUMERICThis is the PAIN TYPE 5 from the last assessment or reassessment
162onset of pain 5105;3FREE TEXTThis is the ONSET OF PAIN 5 from the last assessment or reassessment
163pain worse 5105;4FREE TEXTThis is the PAIN WORSE 5 from the last assessment or reassessment
164pain better 5105;5FREE TEXTThis is the PAIN BETTER 5 from the last assessment or reassessment
165areas of life 5105;6FREE TEXTThis is the AREAS OF LIFE 5 from the last assessment or reassessment
166pain goal 5105;7NUMERICThis is the PAIN GOAL 5 from the last assessment or reassessment
167other pain region 5167;0WORD-PROCESSING
170ability to read170;1BOOLEAN1:YES
0:NO
This is the ABILITY TO READ from the last assessment or reassessment
171ability to write170;2BOOLEAN1:YES
0:NO
This is the ABILITY TO WRITE from the last assessment or reassessment
172educational level170;3POINTER1927.41The patient's educational level. Grade school, high school, college, etc.
180peripheral line 1 location180;1FREE TEXTThis is the PERIPHERAL LINE 1 LOCATION from the last assessment or reassessment
181peripheral line 1 size180;2SET OF CODES16:16 Gauge
18:18 Gauge
20:20 Gauge
22:22 Gauge
O:Other
This is the PERIPHERAL LINE 1 SIZE from the last assessment or reassessment
182peripheral line 1 date ins180;3DATE-TIMEThis is the PERIPHERAL LINE 1 DATE INS from the last assessment or reassessment
183peripheral line 2 location180;4FREE TEXTThis is the PERIPHERAL LINE 2 LOCATION from the last assessment or reassessment
184peripheral line 2 size180;5SET OF CODES16:16 Gauge
18:18 Gauge
20:20 Gauge
22:22 Gauge
O:Other
This is the PERIPHERAL LINE 2 SIZE from the last assessment or reassessment
185peripheral line 2 date ins180;6DATE-TIMEThis is the PERIPHERAL LINE 2 DATE INS from the last assessment or reassessment
186peripheral line 3 location180;7FREE TEXTThis is the PERIPHERAL LINE 3 LOCATION from the last assessment or reassessment
187peripheral line 3 size180;8SET OF CODES16:16 Gauge
18:18 Gauge
20:20 Gauge
22:22 Gauge
O:Other
This is the PERIPHERAL LINE 3 SIZE from the last assessment or reassessment
188peripheral line 3 date ins180;9DATE-TIMEThis is the PERIPHERAL LINE 3 DATE INS from the last assessment or reassessment
190central line 1 type190;1FREE TEXTThis is the CENTRAL LINE 1 TYPE from the last assessment or reassessment
190.5central line 1 location190;2FREE TEXTThis is the CENTRAL LINE 1 LOCATION from the last assessment or reassessment
191central line 1 date ins190;3DATE-TIMEThis is the CENTRAL LINE 1 DATE INS from the last assessment or reassessment
192central line 1 impreg190;4BOOLEAN1:YES
0:NO
This is the CENTRAL LINE 1 IMPREG from the last assessment or reassessment
192.5central line 1 power inj190;5BOOLEAN1:YES
0:NO
This is the CENTRAL LINE 1 POWER INJ from the last assessment or reassessment
193central line 2 type190;6FREE TEXTThis is the CENTRAL LINE 2 TYPE from the last assessment or reassessment
193.5central line 2 location190;7FREE TEXTThis is the CENTRAL LINE 2 LOCATION from the last assessment or reassessment
194central line 2 date ins190;8DATE-TIMEThis is the CENTRAL LINE 2 DATE INS from the last assessment or reassessment
195central line 2 impreg190;9BOOLEAN1:YES
0:NO
This is the CENTRAL LINE 2 IMPREG from the last assessment or reassessment
195.5central line 2 power inj190;10BOOLEAN1:YES
0:NO
This is the CENTRAL LINE 2 POWER INJ from the last assessment or reassessment
196central line 3 type191;1FREE TEXTThis is the CENTRAL LINE 3 TYPE from the last assessment or reassessment
196.5central line 3 location191;2FREE TEXTThis is the CENTRAL LINE 3 LOCATION from the last assessment or reassessment
197central line 3 date ins191;3DATE-TIMEThis is the CENTRAL LINE 3 DATE INS from the last assessment or reassessment
198central line 3 impreg191;4BOOLEAN1:YES
0:NO
This is the CENTRAL LINE 3 IMPREG from the last assessment or reassessment
198.5central line 3 power inj191;5BOOLEAN1:YES
0:NO
This is the CENTRAL LINE 3 POWER INJ from the last assessment or reassessment
200trach type200;1POINTER1927.41This is the TRACH TYPE from the last assessment or reassessment
201other trach type201;0WORD-PROCESSINGThis is the OTHER TRACH TYPE from the last assessment or reassessment
202trach size202;0WORD-PROCESSINGThis is the TRACH SIZE from the last assessment or reassessment
203tobacco screen200;11POINTER1927.41The results of the patient's last tobacco screening.
204resp history200;12FREE TEXTRespiratory problems that a patient has had.
205productive cough200;2BOOLEAN1:YES
0:NO
This is the PRODUCTIVE COUGH from the last assessment or reassessment
206chest tube 1 location200;3FREE TEXTThis is the CHEST TUBE LOCATION 1 from the last assessment or reassessment
206.5chest tube 1 date inserted200;4DATE-TIMEThis is the CHEST TUBE 1 DATE INSERTED from the last assessment or reassessment
207chest tube 2 location200;5FREE TEXTThis is the CHEST TUBE 2 LOCATION from the last assessment or reassessment
207.5chest tube 2 date inserted200;6DATE-TIMEThis is the CHEST TUBE 2 DATE INSERTED from the last assessment or reassessment
208chest tube 3 location200;7FREE TEXTThis is the CHEST TUBE 3 LOCATION from the last assessment or reassessment
208.5chest tube 3 date inserted200;8DATE-TIMEThis is the CHEST TUBE 3 DATE INSERTED from the last assessment or reassessment
209chest tube 4 location200;9FREE TEXTThis is the CHEST TUBE 4 LOCATION from the last assessment or reassessment
209.5chest tube 4 date inserted200;10DATE-TIMEThis is the CHEST TUBE 4 DATE INSERTED from the last assessment or reassessment
210edema-right arm210;1POINTER1927.41This is the EDEMA-RIGHT ARM from the last assessment or reassessment
210.5edema-left arm210;2POINTER1927.41This is the EDEMA-LEFT ARM from the last assessment or reassessment
211edema-right hand210;3POINTER1927.41This is the EDEMA-RIGHT HAND from the last assessment or reassessment
211.5edema-left hand210;4POINTER1927.41This is the EDEMA-LEFT HAND from the last assessment or reassessment
212edema-right leg210;5POINTER1927.41This is the EDEMA-RIGHT LEG from the last assessment or reassessment
212.5edema-left leg210;6POINTER1927.41This is the EDEMA-LEFT LEG from the last assessment or reassessment
213edema-pedal right210;7POINTER1927.41This is the EDEMA-PEDAL RIGHT from the last assessment or reassessment
213.5edema-pedal left210;8POINTER1927.41This is the EDEMA-PEDAL LEFT from the last assessment or reassessment
214edema-facial210;9POINTER1927.41This is the EDEMA-FACIAL from the last assessment or reassessment
215edema-periorbital210;10POINTER1927.41This is the EDEMA-PERIORBITAL from the last assessment or reassessment
216edema-sacral210;11POINTER1927.41This is the EDEMA-SACRAL from the last assessment or reassessment
216.1edema-right hip210.1;1POINTER1927.41This is the EDEMA-RIGHT HIP from the last assessment or reassessment
216.2edema-left hip210.1;2POINTER1927.41This is the EDEMA-LEFT HIP from the last assessment or reassessment.
217extremities210;12FREE TEXTThis is the EXTREMITIES from the last assessment or reassessment
217.1extremities comments217.1;0WORD-PROCESSING
218jugular veneous distortion210;13BOOLEAN1:YES
0:NO
This is the JUGULAR VENEOUS DISTORTION from the last assessment or reassessment
218.1homan's sign210;14FREE TEXTThis is the HOMAN'S SIGN from the last assessment or reassessment
218.2cardiac monitor210;15BOOLEAN1:YES
0:NO
This is the CARDIAC MONITOR from the last assessment or reassessment
219cardiac rhythms210;16POINTER1927.41This is the CARDIAC RHYTHMS from the last assessment or reassessment
219.5cv history210;17FREE TEXTCardiac problems that this patient has had.
219.6other cv history219.6;0WORD-PROCESSING
220autonomic dysreflexia220;1BOOLEAN1:YES
0:NO
This is the AUTONOMIC DYSREFLEXIA from the last assessment or reassessment
221orientation (mentation)220;2FREE TEXTThis is the ORIENTATION (MENTATION) from the last assessment or reassessment
222glasgow coma scale score220;3NUMERICThis is the GLASGOW COMA SCALE SCORE from the last assessment or reassessment
223motor-right arm220;4POINTER1927.41This is the MOTOR-RIGHT ARM from the last assessment or reassessment
223.1motor-left arm220;5POINTER1927.41This is the MOTOR-LEFT ARM from the last assessment or reassessment
223.2motor-right leg220;6POINTER1927.41This is the MOTOR-RIGHT LEG from the last assessment or reassessment
223.3motor-left leg220;7POINTER1927.41This is the MOTOR-LEFT LEG from the last assessment or reassessment
224pupil size220;8POINTER1927.41This is the PUPIL SIZE from the last assessment or reassessment
224.1right eye reactivity220;9POINTER1927.41This is the RIGHT EYE REACTIVITY from the last assessment or reassessment
224.2left eye reactivity220;10POINTER1927.41This is the LEFT EYE REACTIVITY from the last assessment or reassessment
225speech/language220;11POINTER1927.41This is the SPEECH/LANGUAGE from the last assessment or reassessment
226sensations220;12BOOLEAN1:YES
0:NO
This is the SENSATIONS from the last assessment or reassessment
226.5prior sensations226;0WORD-PROCESSINGThis is the PRIOR SENSATIONS from the last assessment or reassessment
227req assistive comm devices220;13BOOLEAN1:YES
0:NO
This is the REQ ASSISTIVE COMM DEVICES from the last assessment or reassessment
227.5prior communication devices227;0WORD-PROCESSINGThis is the PRIOR COMMUNICATION DEVICES from the last assessment or reassessment
228lens implants220;14BOOLEAN1:YES
0:NO
This is the LENS IMPLANTS from the last assessment or reassessment
229neuro history220;15FREE TEXTThe neurological problems this patient has had.
230indwelling catheter size230;1FREE TEXTThis is the FOLEY CATHETER SIZE from the last assessment or reassessment
230.5indwelling catheter date ins230;2DATE-TIMEThis is the FOLEY CATHETER DATE INSERTED from the last assessment or reassessment
231abnormal discharge230;3POINTER1927.41This is the ABNORMAL DISCHARGE from the last assessment or reassessment
232prior pregnancy230;4FREE TEXTThis is the PRIOR PREGNANCY from the last assessment or reassessment
233gu history230;5FREE TEXTThe GU problems this patient has had.
240attitude240;1POINTER1927.41This is the ATTITUDE from the last assessment or reassessment
240.5behavior240;2POINTER1927.41This is the BEHAVIOR from the last assessment or reassessment
241verbal abuse240;3SET OF CODES1:YES
0:NO
2:DECLINES TO ANSWER
This is the VERBAL ABUSE from the last assessment or reassessment
241.1physical abuse240;4SET OF CODES1:YES
0:NO
2:DECLINES TO ANSWER
This is the PHYSICAL ABUSE from the last assessment or reassessment
241.2financial abuse240;5SET OF CODES1:YES
0:NO
2:DECLINES TO ANSWER
This is the FINANCIAL ABUSE from the last assessment or reassessment
241.3rape or sexual abuse240;6SET OF CODES1:YES
0:NO
2:DECLINES TO ANSWER
This is the RAPE OR SEXUAL ABUSE from the last assessment or reassessment
241.4neglect240;7SET OF CODES1:YES
0:NO
2:DECLINES TO ANSWER
This is the NEGLECT from the last assessment or reassessment
241.5na verbal abuse241;11BOOLEAN1:YES
0:NO
This is the nurses judgement of VERBAL ABUSE from the last assessment or reassessment.
241.6na physical abuse241;12BOOLEAN1:YES
0:NO
This is the nurses judgement of PHYSICAL ABUSE from the last assessment or reassessment.
241.7na neglect241;13BOOLEAN1:YES
0:NO
This is the nurses judgement of Neglect from the last assessment or reassessment.
241.8na household victims241;14SET OF CODES1:YES
0:NO
2:UNKNOWN
This is the nurse's judgement of whether others in the patient's household are victims of abuse or neglect by the patient.
242thoughts of harming yourself240;8POINTER1927.41This is the THOUGHTS OF HARMING YOURSELF from the last assessment or reassessment
242.1plan240;9POINTER1927.41This is the PLAN from the last assessment or reassessment
242.11plan description242.11;0WORD-PROCESSING
242.2means available240;10POINTER1927.41This is the MEANS AVAILABLE from the last assessment or reassessment
242.21means description242.21;0WORD-PROCESSING
242.3rehearsed or practiced240;11POINTER1927.41This is the REHEARSED OR PRACTICED from the last assessment or reassessment
242.4heard voices240;12POINTER1927.41This is the HEARD VOICES from the last assessment or reassessment
242.5tried to hurt yourself240;13POINTER1927.41This is the TRIED TO HURT YOURSELF from the last assessment or reassessment
242.6feeling hopeless240;14POINTER1927.41This is the FEELING HOPELESS from the last assessment or reassessment
243has guardian241;1BOOLEAN1:YES
0:NO
This is the HAS GUARDIAN from the last assessment or reassessment
243.01guardian name243.01;0WORD-PROCESSING
243.1legally committed241;2BOOLEAN1:YES
0:NO
This is the LEGALLY COMMITTED from the last assessment or reassessment
243.2danger to themself241;3BOOLEAN1:YES
0:NO
This is the DANGER TO THEMSELF from the last assessment or reassessment
243.3on legal observation241;4BOOLEAN1:YES
0:NO
This is the ON LEGAL OBSERVATION from the last assessment or reassessment
243.4lacks cognitive ability241;5BOOLEAN1:YES
0:NO
This is the LACKS COGNITIVE ABILITY from the last assessment or reassessment
243.5history of escape241;6BOOLEAN1:YES
0:NO
This is the HISTORY OF ESCAPE from the last assessment or reassessment
243.51history of escape from where243.51;0WORD-PROCESSING
244alcohol use241;7POINTER1927.41This is the ALCOHOL USE from the last assessment or reassessment
245use recreational drugs241;8POINTER1927.41This is the USE RECREATIONAL DRUGS from the last assessment or reassessment
246medical marijuana card241;9BOOLEAN1:Yes
0:No
This is the MEDICAL MARIJUANA CARD from the last assessment or reassessment
247contraband241;10BOOLEAN1:YES
0:NO
Did the patient bring in contraband?
248psychosocial history240;15FREE TEXTPsychosocial prblems this patient has had.
250what makes patient upset250;1FREE TEXTThis is the WHAT MAKES PATIENT UPSET from the last assessment or reassessment
250.01other makes patient upset250.01;0WORD-PROCESSING
250.1how act when lose control250;2FREE TEXTThis is the HOW ACT WHEN LOSE CONTROL from the last assessment or reassessment
250.11other lose control250.11;0WORD-PROCESSING
250.2patient calm themself250;3FREE TEXTThis is the PATIENT CALM THEMSELF from the last assessment or reassessment
250.21other calm themselves250.21;0WORD-PROCESSING
251mood251;1FREE TEXTThis is the MOOD from the last assessment or reassessment
251.01other mood251.01;0WORD-PROCESSING
251.1affect251;2FREE TEXTThis is the AFFECT from the last assessment or reassessment
251.11other affect251.11;0WORD-PROCESSING
251.2behavior251;3FREE TEXTThis is the BEHAVIOR from the last assessment or reassessment
251.21other behavior251.21;0WORD-PROCESSING
252behavioral health advanced dir251;4FREE TEXTThis is the BEHAVIORAL HEALTH ADVANCED DIR from the last assessment or reassessment
253notify if placed in restraints250;4SET OF CODES1:YES
0:NO
2:Patient declines to answer
3:Patient unable to answer
Should someone be notified if the patient is placed in restraints?
253.1who to notify if placed in res253.1;0WORD-PROCESSING
254mh history254;1FREE TEXTPrior Mental Health problems this patient has had.
254.1other mh history254.1;0WORD-PROCESSING
255so angry to lose control254;2POINTER1927.41Has the patient ever been so angry as to explode or lose control?
256calm themself254;3POINTER1927.41When the patient gets upset, are they able to calm themself?
260level of assistance260;1POINTER1927.41This is the LEVEL OF ASSISTANCE from the last assessment or reassessment
261level of cooperation260;2POINTER1927.41This is the LEVEL OF COOPERATION from the last assessment or reassessment
262weight bearing capability260;3POINTER1927.41This is the WEIGHT BEARING CAPABILITY from the last assessment or reassessment
263bilateral upper ext strength260;4BOOLEAN1:YES
0:NO
This is the BILATERAL UPPER EXT STRENGTH from the last assessment or reassessment
264applic cond to affect transfer260;5FREE TEXTThis is the APPLIC COND TO AFFECT TRANSFER from the last assessment or reassessment
265katz score260;6NUMERICThis is the KATZ SCORE from the last assessment or reassessment
266decrease in independence260;7POINTER1927.41Was there a decrease in the patient's level of independence in the last 30 days?
267assist patient with260;8FREE TEXTFunctional items that the patient should be assisted with. Ambulating, bathing, etc.
270bowel pattern270;1POINTER1927.41The patient's last bowel pattern.
271gi device types270;2FREE TEXTAny devices in the patient's GI system.
272special food preferences270;3BOOLEAN1:YES
0:NO
Does the patient have any special food preferences?
273nutrition description270;4POINTER1927.41How the patient looks, from a nutition point of view.
274appetite270;5FREE TEXTThe patient's appetite.
275dysphagia screen270;6POINTER1927.41Patient's last Dysphagia screen results (able or not to screen).
275.1tbi270;7BOOLEAN1:YES
0:NO
Diagnosis of new Traumatic Brain Injury?
275.2modified texture diet270;8BOOLEAN1:YES
0:NO
Does the patient need a Modified Texture Diet?
275.3unable to follow commands270;9BOOLEAN1:YES
0:NO
Is the patient unable to follow commands?
275.4wet gurgly voice270;10BOOLEAN1:YES
0:NO
Does the patient have a wet gurgly voice?
275.5drooling while awake270;11BOOLEAN1:YES
0:NO
Is the patient drooling while they're awake?
275.6tongue deviation from midline270;12BOOLEAN1:YES
0:NO
Is the patient's tongue deviating from midline?
276unintentional weight loss/gain270;13SET OF CODES1:YES
0:NO
2:Unknown
Did the patient have an unintentional weight loss or gain in the last month?
277gi history270;14FREE TEXTThe GI problems that this patient has had.
277.1gi other history277.1;0WORD-PROCESSING
278abdominal assessment271;1FREE TEXTThe abdominal assessment on the patient.
278.1other abdominal assessment278.1;0WORD-PROCESSING
280musc history280;1FREE TEXTThe Musculoskeletal history of the patient.
280.1other musc history280.1;0WORD-PROCESSING
281range of motion280;2FREE TEXTThe patient's Range of Motion.
290skin history290;1FREE TEXTThe patient's skin history
291skin risk factors290;2FREE TEXTThe patient's skin risk factors.
292skin patient ed provided290;3FREE TEXTWas education provided to the patient or caregiver about skin care?
293skin breakdown factors290;4FREE TEXTThe Skin Beakdown Factors that this patient has.
300respiratory pattern300;1FREE TEXTThe patient's prior respiratory pattern.
301work of breathing300;2FREE TEXTThe patient's prior Work of Breathing.
302crackels/rales300;3FREE TEXTThe patient's prior Crackles & Rales (breath sounds).
302.1diminished/decrased300;4FREE TEXTThe patient's prior Decreased/Diminshed Breath Sounds.
302.2rhonchi300;5FREE TEXTThe patient's prior Rhonchi breath sounds.
303sputum amount300;6POINTER1927.41The patient's prior amount of sputum.
303.1sputum color300;7FREE TEXTThe patient's prior sputum color.
303.2sputum consistency300;8FREE TEXTThe patient's prior sputum consistency.
304chaplain consult sent304;1BOOLEAN1:YES
0:NO
Was a Chaplain consult sent as part of this care plan from either the Admission Assessment or a prior reassessment?
304.1dp consult sent304;2BOOLEAN1:YES
0:NO
Was a DP consult sent as part of this care plan from either the Admission Assessment or a prior reassessment?
304.2nutrition consult sent304;3BOOLEAN1:YES
0:NO
Was a Nutrition consult sent as part of this care plan from either the Admission Assessment or a prior reassessment?
304.3speech consult sent304;4BOOLEAN1:YES
0:NO
Was a Speech consult sent as part of this care plan from either the Admission Assessment or a prior reassessment?
304.4social work consult sent304;5BOOLEAN1:YES
0:NO
Was a Social Work consult sent as part of this care plan from either the Admission Assessment or a prior reassessment?

Referenced by 5 types

  1. NUPA CARE PLAN PRESSURE ULCERS (1927.401) -- care plan
  2. NUPA CARE PLAN IVS (1927.402) -- care plan
  3. NUPA CARE PLAN GI/GU DEVICES (1927.403) -- care plan
  4. NUPA CARE PLAN TEXT CHANGE LOG (1927.5) -- care plan
  5. NUPA DISCHARGE PLANNING GOAL COMMENTS (1927.6) -- care plan