# | Name | Location | Type | Details | Index | Description |
---|---|---|---|---|---|---|
.01 | date/time entered(+) | 0;1 | DATE-TIME | B | This is the DATE/TIME ENTERED from the last assessment or reassessment | |
1 | patient | 0;2 | POINTER | 2 | C | This is the PATIENT from the last assessment or reassessment |
2 | entered by | 0;3 | POINTER | 200 | This is the ENTERED BY from the last assessment or reassessment | |
3 | guardian name | 0;4 | FREE TEXT | This is the patient's legal guardian. | ||
4 | primary language | 0;5 | FREE TEXT | This is the patient's primary language. | ||
4.5 | accomplish by this hosp | 15;0 | WORD-PROCESSING | |||
5 | cultural practices | 0;6 | BOOLEAN | 1:YES 0:NO | These are any cultural practices that the patient may have that the nurse believes may affect care. | |
5.1 | cultural practices description | 2;0 | WORD-PROCESSING | This is the CULTURAL PRACTICES DESCRIPTION from the last assessment or reassessment | ||
6 | blood transfusion concerns | 0;7 | BOOLEAN | 1:YES 0:NO | Any blood tranfusion concerns that patient may have. | |
6.1 | blood transfusion description | 3;0 | WORD-PROCESSING | This is the BLOOD TRANSFUSION DESCRIPTION from the last assessment or reassessment | ||
7 | advance directive | 0;8 | BOOLEAN | 1:YES 0:NO | Does the patient have any advance directives? | |
7.1 | advance directive location | 4;0 | WORD-PROCESSING | This is the ADVANCE DIRECTIVE LOCATION from the last assessment or reassessment | ||
8 | special diet needs | 0;9 | BOOLEAN | 1:YES 0:NO | Does the patient have any special diet needs? | |
8.1 | special diet needs description | 5;0 | WORD-PROCESSING | This is the SPECIAL DIET NEEDS DESCRIPTION from the last assessment or reassessment | ||
10 | suspected victim of abuse/negl | 0;10 | BOOLEAN | 1:YES 0:NO | Does the nurse suspect that the patient is a victim of abuse or neglect? | |
11 | organ donor | 0;11 | BOOLEAN | 1:YES 0:NO | Is the patient an organ donor? | |
12 | allergy pointer | 1;0 | MULTIPLE | 1927.412 | List of the patients allergies as of the moment of the care plan. | |
13 | precautions | 0;14 | FREE TEXT | MRSA precautions to take around this patient. | ||
14 | level of understanding | 0;15 | POINTER | 1927.41 | The level of understanding that a patient has of the education they were just given on MRSA. | |
17 | precautions (flags) | 6;0 | MULTIPLE | 1927.417 | Any precauions or flags (local or national) as of the moment of the care plan. | |
18 | latest dnr note | 0;12 | POINTER | 8925 | Latest DNR note, if any, on file for this patient. | |
19 | ward | 0;13 | POINTER | 44 | Ward that the patient was on as of the moment of the care plan. | |
20 | oriented | 10;1 | FREE TEXT | Was the patient oriented to his/her room as of the moment of the care plan. | ||
21 | able to assess education | 10;2 | BOOLEAN | 1:YES 0:NO | Was the nurse able to assess the patient's level of education? | |
22 | learns best by | 10;3 | FREE TEXT | How does the patient learn best? Hearing, seeing, etc. | ||
23 | education preferred | 10;4 | FREE TEXT | What kind of education does the patient prefer? Computer based, group classes, etc. | ||
24 | readiness to learn | 10;5 | POINTER | 1927.41 | What is the patient's readiness to learn? Ready to learn, not ready, sedated, etc. | |
25 | barriers to learning | 10;6 | FREE TEXT | Does the patient have any barriers to learning? None, mental status, hearing, etc. | ||
25.1 | barriers to learning descrip | 11;0 | WORD-PROCESSING | This is the BARRIERS TO LEARNING DESCRIP from the last assessment or reassessment | ||
26 | knowledge of current illness | 10;7 | SET OF CODES | 0:NONE 1:LIMITED 2:EXTENSIVE | What is the patient's level of knowledge of his/her illness? None, limited, or extensive. | |
27 | educational info provided | 10;8 | FREE TEXT | Was any educational information provided to the patient? BCMA, Managing Your Pain, etc. | ||
30 | interventions | 20;0 | MULTIPLE | 1927.47 | Nursing Interventions provided to correct problems that a patient has. | |
31 | problems | 21;0 | MULTIPLE | 1927.431 | List of problems that a patient has. | |
32 | problem comments | 12;0 | WORD-PROCESSING | Medical comments on the patient's problems. | ||
40 | disch to home wo add services | 30;1 | BOOLEAN | 1:YES 0:NO | Should the patient be discharged to his/her home without additional services? | |
41 | dp goals | 30;2 | FREE TEXT | Does the patient need assistance from a Discharge Planning nurse or a Social Worker? | ||
41.1 | dp goals other 1 | 41;1 | FREE TEXT | The "Other 1" free text goal entered by the user. | ||
41.2 | dp goals other 2 | 41;2 | FREE TEXT | The "Other 2" free text goal entered by the user. | ||
41.3 | dp goals other 3 | 41;3 | FREE TEXT | The "Other 3" free text goal entered by the user. | ||
42 | braden score | 30;3 | NUMERIC | The patient's Braden Score as of the moment of the care plan. | ||
42.5 | braden score date | 30;5 | DATE-TIME | Date that the Braden test was done. | ||
43 | morse score | 30;4 | NUMERIC | The patient's Morse Fall score as of the moment of the care plan. | ||
43.5 | morse score date | 30;6 | DATE-TIME | Date that the Morse Fall test was done. | ||
44 | family support involved in dp | 7;0 | WORD-PROCESSING | Does the patient need family support in the planning of his/her discharge? | ||
45 | dp observations/comments | 31;0 | WORD-PROCESSING | |||
50 | general observations/comments | 13;0 | WORD-PROCESSING | General comments on this care plan. | ||
60 | problem evaluations | 8;0 | MULTIPLE | 1927.49 | Log of evaluations of the patient's problems. | |
61 | intervention evaluation | 9;0 | MULTIPLE | 1927.461 | Log of interventions to help the patient's problems. | |
70 | bed to chair | 14;1 | FREE TEXT | This is the BED TO CHAIR from the last assessment or reassessment | ||
70.5 | bed to chair staff | 14;2 | NUMERIC | This is the BED TO CHAIR STAFF from the last assessment or reassessment | ||
71 | bed to stretcher | 14;3 | FREE TEXT | This is the BED TO STRETCHER from the last assessment or reassessment | ||
71.5 | bed to stretcher staff | 14;4 | NUMERIC | This is the BED TO STRETCHER STAFF from the last assessment or reassessment | ||
72 | chair to stretcher | 14;5 | FREE TEXT | This is the CHAIR TO STRETCHER from the last assessment or reassessment | ||
72.5 | chair to stretcher staff | 14;6 | NUMERIC | This is the CHAIR TO STRETCHER STAFF from the last assessment or reassessment | ||
73 | repos in bed | 14;7 | FREE TEXT | This is the REPOS IN BED from the last assessment or reassessment | ||
73.5 | repos in bed staff | 14;8 | NUMERIC | This is the REPOS IN BED STAFF from the last assessment or reassessment | ||
74 | repos in chair | 14;9 | FREE TEXT | This is the REPOS IN CHAIR from the last assessment or reassessment | ||
74.5 | repos in chair staff | 14;10 | NUMERIC | This is the REPOS IN CHAIR STAFF from the last assessment or reassessment | ||
75 | transfer from floor | 14;11 | FREE TEXT | This is the TRANSFER FROM FLOOR from the last assessment or reassessment | ||
75.5 | transfer from floor staff | 14;12 | NUMERIC | This is the TRANSFER FROM FLOOR STAFF from the last assessment or reassessment | ||
76 | sling type | 14;13 | POINTER | 1927.41 | This is the SLING TYPE from the last assessment or reassessment | |
77 | sling size | 14;14 | POINTER | 1927.41 | This is the SLING SIZE from the last assessment or reassessment | |
100 | gen info done(+) | 100;1 | BOOLEAN | 1:YES 0:NO | Yes/No flag noting if the General Info tab has been completed. | |
102 | resp done(+) | 100;3 | BOOLEAN | 1:YES 0:NO | Yes/No flag noting if the Respiratory tab has been completed. | |
103 | cv done | 100;4 | BOOLEAN | 1:YES 0:NO | Yes/No flag noting if the CV tab has been completed. | |
104 | neuro done(+) | 100;5 | BOOLEAN | 1:YES 0:NO | Yes/No flag noting if the Neuro tab has been completed. | |
105 | gi done | 100;6 | BOOLEAN | 1:YES 0:NO | Yes/No flag noting if the GI tab has been completed. | |
106 | gu done(+) | 100;7 | BOOLEAN | 1:YES 0:NO | Yes/No flag noting if the GU tab has been completed. | |
107 | ms done(+) | 100;8 | BOOLEAN | 1:YES 0:NO | Yes/No flag noting if the Musculoskeletal tab has been completed. | |
108 | skin done(+) | 100;9 | BOOLEAN | 1:YES 0:NO | Yes/No flag noting if the Skin tab has been completed. | |
109 | ps done(+) | 100;10 | BOOLEAN | 1:YES 0:NO | Yes/No flag noting if the Psychosocial tab has been completed. | |
110 | mh done(+) | 100;11 | BOOLEAN | 1:YES 0:NO | Yes/No flag noting if the Mental Health tab has been completed. | |
111 | func done(+) | 100;12 | BOOLEAN | 1:YES 0:NO | Yes/No flag noting if the Functional tab has been completed. | |
112 | dp done(+) | 100;13 | BOOLEAN | 1:YES 0:NO | Yes/No flag noting if the Discharge Planning tab has been completed. | |
113 | rel practices for chaplain | 100;14 | BOOLEAN | 1:YES 0:NO | This is the REL PRACTICES FOR CHAPLAIN from the last assessment or reassessment | |
114 | immediate chaplain visit | 100;15 | BOOLEAN | 1:YES 0:NO | This is the IMMEDIATE CHAPLAIN VISIT from the last assessment or reassessment | |
114.1 | should clergy be notified | 100;22 | BOOLEAN | 1:YES 0:NO | This is the SHOULD CLERGY BE NOTIFIED from the last assessment or reassessment | |
115 | recv info on ad | 100;16 | BOOLEAN | 1:YES 0:NO | This is the RECV INFO ON AD from the last assessment or reassessment | |
116 | initiate or change ad | 100;17 | BOOLEAN | 1:YES 0:NO | This is the INITIATE OR CHANGE AD from the last assessment or reassessment | |
117 | test for mrsa brochure given | 100;18 | BOOLEAN | 1:YES 0:NO | This is the TEST FOR MRSA BROCHURE GIVEN from the last assessment or reassessment | |
117.1 | patient authorize nares | 100;19 | BOOLEAN | 1:YES 0:NO | This is the PATIENT AUTHORIZE NARES from the last assessment or reassessment | |
117.2 | nares preformed | 100;20 | BOOLEAN | 1:YES 0:NO | This is the NARES PREFORMED from the last assessment or reassessment | |
118 | infection control ed provided | 100;21 | BOOLEAN | 1:YES 0:NO | This is the INFECTION CONTROL ED PROVIDED from the last assessment or reassessment | |
120 | pain location 1 | 101;1 | FREE TEXT | This is the PAIN LOCATION 1 from the last assessment or reassessment | ||
121 | pain type 1 | 101;2 | NUMERIC | This is the PAIN TYPE 1 from the last assessment or reassessment | ||
122 | onset of pain 1 | 101;3 | FREE TEXT | This is the ONSET OF PAIN 1 from the last assessment or reassessment | ||
123 | pain worse 1 | 101;4 | FREE TEXT | This is the PAIN WORSE 1 from the last assessment or reassessment | ||
124 | pain better 1 | 101;5 | FREE TEXT | This is the PAIN BETTER 1 from the last assessment or reassessment | ||
125 | areas of life 1 | 101;6 | FREE TEXT | This is the AREAS OF LIFE 1 from the last assessment or reassessment | ||
126 | pain goal 1 | 101;7 | NUMERIC | This is the PAIN GOAL 1 from the last assessment or reassessment | ||
127 | other pain region 1 | 127;0 | WORD-PROCESSING | |||
130 | pain location 2 | 102;1 | FREE TEXT | This is the PAIN LOCATION 2 from the last assessment or reassessment | ||
131 | pain type 2 | 102;2 | NUMERIC | This is the PAIN TYPE 2 from the last assessment or reassessment | ||
132 | onset of pain 2 | 102;3 | FREE TEXT | This is the ONSET OF PAIN 2 from the last assessment or reassessment | ||
133 | pain worse 2 | 102;4 | FREE TEXT | This is the PAIN WORSE 2 from the last assessment or reassessment | ||
134 | pain better 2 | 102;5 | FREE TEXT | This is the PAIN BETTER 2 from the last assessment or reassessment | ||
135 | areas of life 2 | 102;6 | FREE TEXT | This is the AREAS OF LIFE 2 from the last assessment or reassessment | ||
136 | pain goal 2 | 102;7 | NUMERIC | This is the PAIN GOAL 2 from the last assessment or reassessment | ||
137 | other pain region 2 | 137;0 | WORD-PROCESSING | |||
140 | pain location 3 | 103;1 | FREE TEXT | This is the PAIN LOCATION 3 from the last assessment or reassessment | ||
141 | pain type 3 | 103;2 | NUMERIC | This is the PAIN TYPE 3 from the last assessment or reassessment | ||
142 | onset of pain 3 | 103;3 | FREE TEXT | This is the ONSET OF PAIN 3 from the last assessment or reassessment | ||
143 | pain worse 3 | 103;4 | FREE TEXT | This is the PAIN WORSE 3 from the last assessment or reassessment | ||
144 | pain better 3 | 103;5 | FREE TEXT | This is the PAIN BETTER 3 from the last assessment or reassessment | ||
145 | areas of life 3 | 103;6 | FREE TEXT | This is the AREAS OF LIFE 3 from the last assessment or reassessment | ||
146 | pain goal 3 | 103;7 | NUMERIC | This is the PAIN GOAL 3 from the last assessment or reassessment | ||
147 | other pain region 3 | 147;0 | WORD-PROCESSING | |||
150 | pain location 4 | 104;1 | FREE TEXT | This is the PAIN LOCATION 4 from the last assessment or reassessment | ||
151 | pain type 4 | 104;2 | NUMERIC | This is the PAIN TYPE 4 from the last assessment or reassessment | ||
152 | onset of pain 4 | 104;3 | FREE TEXT | This is the ONSET OF PAIN 4 from the last assessment or reassessment | ||
153 | pain worse 4 | 104;4 | FREE TEXT | This is the PAIN WORSE 4 from the last assessment or reassessment | ||
154 | pain better 4 | 104;5 | FREE TEXT | This is the PAIN BETTER 4 from the last assessment or reassessment | ||
155 | areas of life 4 | 104;6 | FREE TEXT | This is the AREAS OF LIFE 4 from the last assessment or reassessment | ||
156 | pain goal 4 | 104;7 | NUMERIC | This is the PAIN GOAL 4 from the last assessment or reassessment | ||
157 | other pain region 4 | 157;0 | WORD-PROCESSING | |||
160 | pain location 5 | 105;1 | FREE TEXT | This is the PAIN LOCATION 5 from the last assessment or reassessment | ||
161 | pain type 5 | 105;2 | NUMERIC | This is the PAIN TYPE 5 from the last assessment or reassessment | ||
162 | onset of pain 5 | 105;3 | FREE TEXT | This is the ONSET OF PAIN 5 from the last assessment or reassessment | ||
163 | pain worse 5 | 105;4 | FREE TEXT | This is the PAIN WORSE 5 from the last assessment or reassessment | ||
164 | pain better 5 | 105;5 | FREE TEXT | This is the PAIN BETTER 5 from the last assessment or reassessment | ||
165 | areas of life 5 | 105;6 | FREE TEXT | This is the AREAS OF LIFE 5 from the last assessment or reassessment | ||
166 | pain goal 5 | 105;7 | NUMERIC | This is the PAIN GOAL 5 from the last assessment or reassessment | ||
167 | other pain region 5 | 167;0 | WORD-PROCESSING | |||
170 | ability to read | 170;1 | BOOLEAN | 1:YES 0:NO | This is the ABILITY TO READ from the last assessment or reassessment | |
171 | ability to write | 170;2 | BOOLEAN | 1:YES 0:NO | This is the ABILITY TO WRITE from the last assessment or reassessment | |
172 | educational level | 170;3 | POINTER | 1927.41 | The patient's educational level. Grade school, high school, college, etc. | |
180 | peripheral line 1 location | 180;1 | FREE TEXT | This is the PERIPHERAL LINE 1 LOCATION from the last assessment or reassessment | ||
181 | peripheral line 1 size | 180;2 | SET OF CODES | 16:16 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 | |
182 | peripheral line 1 date ins | 180;3 | DATE-TIME | This is the PERIPHERAL LINE 1 DATE INS from the last assessment or reassessment | ||
183 | peripheral line 2 location | 180;4 | FREE TEXT | This is the PERIPHERAL LINE 2 LOCATION from the last assessment or reassessment | ||
184 | peripheral line 2 size | 180;5 | SET OF CODES | 16:16 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 | |
185 | peripheral line 2 date ins | 180;6 | DATE-TIME | This is the PERIPHERAL LINE 2 DATE INS from the last assessment or reassessment | ||
186 | peripheral line 3 location | 180;7 | FREE TEXT | This is the PERIPHERAL LINE 3 LOCATION from the last assessment or reassessment | ||
187 | peripheral line 3 size | 180;8 | SET OF CODES | 16:16 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 | |
188 | peripheral line 3 date ins | 180;9 | DATE-TIME | This is the PERIPHERAL LINE 3 DATE INS from the last assessment or reassessment | ||
190 | central line 1 type | 190;1 | FREE TEXT | This is the CENTRAL LINE 1 TYPE from the last assessment or reassessment | ||
190.5 | central line 1 location | 190;2 | FREE TEXT | This is the CENTRAL LINE 1 LOCATION from the last assessment or reassessment | ||
191 | central line 1 date ins | 190;3 | DATE-TIME | This is the CENTRAL LINE 1 DATE INS from the last assessment or reassessment | ||
192 | central line 1 impreg | 190;4 | BOOLEAN | 1:YES 0:NO | This is the CENTRAL LINE 1 IMPREG from the last assessment or reassessment | |
192.5 | central line 1 power inj | 190;5 | BOOLEAN | 1:YES 0:NO | This is the CENTRAL LINE 1 POWER INJ from the last assessment or reassessment | |
193 | central line 2 type | 190;6 | FREE TEXT | This is the CENTRAL LINE 2 TYPE from the last assessment or reassessment | ||
193.5 | central line 2 location | 190;7 | FREE TEXT | This is the CENTRAL LINE 2 LOCATION from the last assessment or reassessment | ||
194 | central line 2 date ins | 190;8 | DATE-TIME | This is the CENTRAL LINE 2 DATE INS from the last assessment or reassessment | ||
195 | central line 2 impreg | 190;9 | BOOLEAN | 1:YES 0:NO | This is the CENTRAL LINE 2 IMPREG from the last assessment or reassessment | |
195.5 | central line 2 power inj | 190;10 | BOOLEAN | 1:YES 0:NO | This is the CENTRAL LINE 2 POWER INJ from the last assessment or reassessment | |
196 | central line 3 type | 191;1 | FREE TEXT | This is the CENTRAL LINE 3 TYPE from the last assessment or reassessment | ||
196.5 | central line 3 location | 191;2 | FREE TEXT | This is the CENTRAL LINE 3 LOCATION from the last assessment or reassessment | ||
197 | central line 3 date ins | 191;3 | DATE-TIME | This is the CENTRAL LINE 3 DATE INS from the last assessment or reassessment | ||
198 | central line 3 impreg | 191;4 | BOOLEAN | 1:YES 0:NO | This is the CENTRAL LINE 3 IMPREG from the last assessment or reassessment | |
198.5 | central line 3 power inj | 191;5 | BOOLEAN | 1:YES 0:NO | This is the CENTRAL LINE 3 POWER INJ from the last assessment or reassessment | |
200 | trach type | 200;1 | POINTER | 1927.41 | This is the TRACH TYPE from the last assessment or reassessment | |
201 | other trach type | 201;0 | WORD-PROCESSING | This is the OTHER TRACH TYPE from the last assessment or reassessment | ||
202 | trach size | 202;0 | WORD-PROCESSING | This is the TRACH SIZE from the last assessment or reassessment | ||
203 | tobacco screen | 200;11 | POINTER | 1927.41 | The results of the patient's last tobacco screening. | |
204 | resp history | 200;12 | FREE TEXT | Respiratory problems that a patient has had. | ||
205 | productive cough | 200;2 | BOOLEAN | 1:YES 0:NO | This is the PRODUCTIVE COUGH from the last assessment or reassessment | |
206 | chest tube 1 location | 200;3 | FREE TEXT | This is the CHEST TUBE LOCATION 1 from the last assessment or reassessment | ||
206.5 | chest tube 1 date inserted | 200;4 | DATE-TIME | This is the CHEST TUBE 1 DATE INSERTED from the last assessment or reassessment | ||
207 | chest tube 2 location | 200;5 | FREE TEXT | This is the CHEST TUBE 2 LOCATION from the last assessment or reassessment | ||
207.5 | chest tube 2 date inserted | 200;6 | DATE-TIME | This is the CHEST TUBE 2 DATE INSERTED from the last assessment or reassessment | ||
208 | chest tube 3 location | 200;7 | FREE TEXT | This is the CHEST TUBE 3 LOCATION from the last assessment or reassessment | ||
208.5 | chest tube 3 date inserted | 200;8 | DATE-TIME | This is the CHEST TUBE 3 DATE INSERTED from the last assessment or reassessment | ||
209 | chest tube 4 location | 200;9 | FREE TEXT | This is the CHEST TUBE 4 LOCATION from the last assessment or reassessment | ||
209.5 | chest tube 4 date inserted | 200;10 | DATE-TIME | This is the CHEST TUBE 4 DATE INSERTED from the last assessment or reassessment | ||
210 | edema-right arm | 210;1 | POINTER | 1927.41 | This is the EDEMA-RIGHT ARM from the last assessment or reassessment | |
210.5 | edema-left arm | 210;2 | POINTER | 1927.41 | This is the EDEMA-LEFT ARM from the last assessment or reassessment | |
211 | edema-right hand | 210;3 | POINTER | 1927.41 | This is the EDEMA-RIGHT HAND from the last assessment or reassessment | |
211.5 | edema-left hand | 210;4 | POINTER | 1927.41 | This is the EDEMA-LEFT HAND from the last assessment or reassessment | |
212 | edema-right leg | 210;5 | POINTER | 1927.41 | This is the EDEMA-RIGHT LEG from the last assessment or reassessment | |
212.5 | edema-left leg | 210;6 | POINTER | 1927.41 | This is the EDEMA-LEFT LEG from the last assessment or reassessment | |
213 | edema-pedal right | 210;7 | POINTER | 1927.41 | This is the EDEMA-PEDAL RIGHT from the last assessment or reassessment | |
213.5 | edema-pedal left | 210;8 | POINTER | 1927.41 | This is the EDEMA-PEDAL LEFT from the last assessment or reassessment | |
214 | edema-facial | 210;9 | POINTER | 1927.41 | This is the EDEMA-FACIAL from the last assessment or reassessment | |
215 | edema-periorbital | 210;10 | POINTER | 1927.41 | This is the EDEMA-PERIORBITAL from the last assessment or reassessment | |
216 | edema-sacral | 210;11 | POINTER | 1927.41 | This is the EDEMA-SACRAL from the last assessment or reassessment | |
216.1 | edema-right hip | 210.1;1 | POINTER | 1927.41 | This is the EDEMA-RIGHT HIP from the last assessment or reassessment | |
216.2 | edema-left hip | 210.1;2 | POINTER | 1927.41 | This is the EDEMA-LEFT HIP from the last assessment or reassessment. | |
217 | extremities | 210;12 | FREE TEXT | This is the EXTREMITIES from the last assessment or reassessment | ||
217.1 | extremities comments | 217.1;0 | WORD-PROCESSING | |||
218 | jugular veneous distortion | 210;13 | BOOLEAN | 1:YES 0:NO | This is the JUGULAR VENEOUS DISTORTION from the last assessment or reassessment | |
218.1 | homan's sign | 210;14 | FREE TEXT | This is the HOMAN'S SIGN from the last assessment or reassessment | ||
218.2 | cardiac monitor | 210;15 | BOOLEAN | 1:YES 0:NO | This is the CARDIAC MONITOR from the last assessment or reassessment | |
219 | cardiac rhythms | 210;16 | POINTER | 1927.41 | This is the CARDIAC RHYTHMS from the last assessment or reassessment | |
219.5 | cv history | 210;17 | FREE TEXT | Cardiac problems that this patient has had. | ||
219.6 | other cv history | 219.6;0 | WORD-PROCESSING | |||
220 | autonomic dysreflexia | 220;1 | BOOLEAN | 1:YES 0:NO | This is the AUTONOMIC DYSREFLEXIA from the last assessment or reassessment | |
221 | orientation (mentation) | 220;2 | FREE TEXT | This is the ORIENTATION (MENTATION) from the last assessment or reassessment | ||
222 | glasgow coma scale score | 220;3 | NUMERIC | This is the GLASGOW COMA SCALE SCORE from the last assessment or reassessment | ||
223 | motor-right arm | 220;4 | POINTER | 1927.41 | This is the MOTOR-RIGHT ARM from the last assessment or reassessment | |
223.1 | motor-left arm | 220;5 | POINTER | 1927.41 | This is the MOTOR-LEFT ARM from the last assessment or reassessment | |
223.2 | motor-right leg | 220;6 | POINTER | 1927.41 | This is the MOTOR-RIGHT LEG from the last assessment or reassessment | |
223.3 | motor-left leg | 220;7 | POINTER | 1927.41 | This is the MOTOR-LEFT LEG from the last assessment or reassessment | |
224 | pupil size | 220;8 | POINTER | 1927.41 | This is the PUPIL SIZE from the last assessment or reassessment | |
224.1 | right eye reactivity | 220;9 | POINTER | 1927.41 | This is the RIGHT EYE REACTIVITY from the last assessment or reassessment | |
224.2 | left eye reactivity | 220;10 | POINTER | 1927.41 | This is the LEFT EYE REACTIVITY from the last assessment or reassessment | |
225 | speech/language | 220;11 | POINTER | 1927.41 | This is the SPEECH/LANGUAGE from the last assessment or reassessment | |
226 | sensations | 220;12 | BOOLEAN | 1:YES 0:NO | This is the SENSATIONS from the last assessment or reassessment | |
226.5 | prior sensations | 226;0 | WORD-PROCESSING | This is the PRIOR SENSATIONS from the last assessment or reassessment | ||
227 | req assistive comm devices | 220;13 | BOOLEAN | 1:YES 0:NO | This is the REQ ASSISTIVE COMM DEVICES from the last assessment or reassessment | |
227.5 | prior communication devices | 227;0 | WORD-PROCESSING | This is the PRIOR COMMUNICATION DEVICES from the last assessment or reassessment | ||
228 | lens implants | 220;14 | BOOLEAN | 1:YES 0:NO | This is the LENS IMPLANTS from the last assessment or reassessment | |
229 | neuro history | 220;15 | FREE TEXT | The neurological problems this patient has had. | ||
230 | indwelling catheter size | 230;1 | FREE TEXT | This is the FOLEY CATHETER SIZE from the last assessment or reassessment | ||
230.5 | indwelling catheter date ins | 230;2 | DATE-TIME | This is the FOLEY CATHETER DATE INSERTED from the last assessment or reassessment | ||
231 | abnormal discharge | 230;3 | POINTER | 1927.41 | This is the ABNORMAL DISCHARGE from the last assessment or reassessment | |
232 | prior pregnancy | 230;4 | FREE TEXT | This is the PRIOR PREGNANCY from the last assessment or reassessment | ||
233 | gu history | 230;5 | FREE TEXT | The GU problems this patient has had. | ||
240 | attitude | 240;1 | POINTER | 1927.41 | This is the ATTITUDE from the last assessment or reassessment | |
240.5 | behavior | 240;2 | POINTER | 1927.41 | This is the BEHAVIOR from the last assessment or reassessment | |
241 | verbal abuse | 240;3 | SET OF CODES | 1:YES 0:NO 2:DECLINES TO ANSWER | This is the VERBAL ABUSE from the last assessment or reassessment | |
241.1 | physical abuse | 240;4 | SET OF CODES | 1:YES 0:NO 2:DECLINES TO ANSWER | This is the PHYSICAL ABUSE from the last assessment or reassessment | |
241.2 | financial abuse | 240;5 | SET OF CODES | 1:YES 0:NO 2:DECLINES TO ANSWER | This is the FINANCIAL ABUSE from the last assessment or reassessment | |
241.3 | rape or sexual abuse | 240;6 | SET OF CODES | 1:YES 0:NO 2:DECLINES TO ANSWER | This is the RAPE OR SEXUAL ABUSE from the last assessment or reassessment | |
241.4 | neglect | 240;7 | SET OF CODES | 1:YES 0:NO 2:DECLINES TO ANSWER | This is the NEGLECT from the last assessment or reassessment | |
241.5 | na verbal abuse | 241;11 | BOOLEAN | 1:YES 0:NO | This is the nurses judgement of VERBAL ABUSE from the last assessment or reassessment. | |
241.6 | na physical abuse | 241;12 | BOOLEAN | 1:YES 0:NO | This is the nurses judgement of PHYSICAL ABUSE from the last assessment or reassessment. | |
241.7 | na neglect | 241;13 | BOOLEAN | 1:YES 0:NO | This is the nurses judgement of Neglect from the last assessment or reassessment. | |
241.8 | na household victims | 241;14 | SET OF CODES | 1: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. | |
242 | thoughts of harming yourself | 240;8 | POINTER | 1927.41 | This is the THOUGHTS OF HARMING YOURSELF from the last assessment or reassessment | |
242.1 | plan | 240;9 | POINTER | 1927.41 | This is the PLAN from the last assessment or reassessment | |
242.11 | plan description | 242.11;0 | WORD-PROCESSING | |||
242.2 | means available | 240;10 | POINTER | 1927.41 | This is the MEANS AVAILABLE from the last assessment or reassessment | |
242.21 | means description | 242.21;0 | WORD-PROCESSING | |||
242.3 | rehearsed or practiced | 240;11 | POINTER | 1927.41 | This is the REHEARSED OR PRACTICED from the last assessment or reassessment | |
242.4 | heard voices | 240;12 | POINTER | 1927.41 | This is the HEARD VOICES from the last assessment or reassessment | |
242.5 | tried to hurt yourself | 240;13 | POINTER | 1927.41 | This is the TRIED TO HURT YOURSELF from the last assessment or reassessment | |
242.6 | feeling hopeless | 240;14 | POINTER | 1927.41 | This is the FEELING HOPELESS from the last assessment or reassessment | |
243 | has guardian | 241;1 | BOOLEAN | 1:YES 0:NO | This is the HAS GUARDIAN from the last assessment or reassessment | |
243.01 | guardian name | 243.01;0 | WORD-PROCESSING | |||
243.1 | legally committed | 241;2 | BOOLEAN | 1:YES 0:NO | This is the LEGALLY COMMITTED from the last assessment or reassessment | |
243.2 | danger to themself | 241;3 | BOOLEAN | 1:YES 0:NO | This is the DANGER TO THEMSELF from the last assessment or reassessment | |
243.3 | on legal observation | 241;4 | BOOLEAN | 1:YES 0:NO | This is the ON LEGAL OBSERVATION from the last assessment or reassessment | |
243.4 | lacks cognitive ability | 241;5 | BOOLEAN | 1:YES 0:NO | This is the LACKS COGNITIVE ABILITY from the last assessment or reassessment | |
243.5 | history of escape | 241;6 | BOOLEAN | 1:YES 0:NO | This is the HISTORY OF ESCAPE from the last assessment or reassessment | |
243.51 | history of escape from where | 243.51;0 | WORD-PROCESSING | |||
244 | alcohol use | 241;7 | POINTER | 1927.41 | This is the ALCOHOL USE from the last assessment or reassessment | |
245 | use recreational drugs | 241;8 | POINTER | 1927.41 | This is the USE RECREATIONAL DRUGS from the last assessment or reassessment | |
246 | medical marijuana card | 241;9 | BOOLEAN | 1:Yes 0:No | This is the MEDICAL MARIJUANA CARD from the last assessment or reassessment | |
247 | contraband | 241;10 | BOOLEAN | 1:YES 0:NO | Did the patient bring in contraband? | |
248 | psychosocial history | 240;15 | FREE TEXT | Psychosocial prblems this patient has had. | ||
250 | what makes patient upset | 250;1 | FREE TEXT | This is the WHAT MAKES PATIENT UPSET from the last assessment or reassessment | ||
250.01 | other makes patient upset | 250.01;0 | WORD-PROCESSING | |||
250.1 | how act when lose control | 250;2 | FREE TEXT | This is the HOW ACT WHEN LOSE CONTROL from the last assessment or reassessment | ||
250.11 | other lose control | 250.11;0 | WORD-PROCESSING | |||
250.2 | patient calm themself | 250;3 | FREE TEXT | This is the PATIENT CALM THEMSELF from the last assessment or reassessment | ||
250.21 | other calm themselves | 250.21;0 | WORD-PROCESSING | |||
251 | mood | 251;1 | FREE TEXT | This is the MOOD from the last assessment or reassessment | ||
251.01 | other mood | 251.01;0 | WORD-PROCESSING | |||
251.1 | affect | 251;2 | FREE TEXT | This is the AFFECT from the last assessment or reassessment | ||
251.11 | other affect | 251.11;0 | WORD-PROCESSING | |||
251.2 | behavior | 251;3 | FREE TEXT | This is the BEHAVIOR from the last assessment or reassessment | ||
251.21 | other behavior | 251.21;0 | WORD-PROCESSING | |||
252 | behavioral health advanced dir | 251;4 | FREE TEXT | This is the BEHAVIORAL HEALTH ADVANCED DIR from the last assessment or reassessment | ||
253 | notify if placed in restraints | 250;4 | SET OF CODES | 1:YES 0:NO 2:Patient declines to answer 3:Patient unable to answer | Should someone be notified if the patient is placed in restraints? | |
253.1 | who to notify if placed in res | 253.1;0 | WORD-PROCESSING | |||
254 | mh history | 254;1 | FREE TEXT | Prior Mental Health problems this patient has had. | ||
254.1 | other mh history | 254.1;0 | WORD-PROCESSING | |||
255 | so angry to lose control | 254;2 | POINTER | 1927.41 | Has the patient ever been so angry as to explode or lose control? | |
256 | calm themself | 254;3 | POINTER | 1927.41 | When the patient gets upset, are they able to calm themself? | |
260 | level of assistance | 260;1 | POINTER | 1927.41 | This is the LEVEL OF ASSISTANCE from the last assessment or reassessment | |
261 | level of cooperation | 260;2 | POINTER | 1927.41 | This is the LEVEL OF COOPERATION from the last assessment or reassessment | |
262 | weight bearing capability | 260;3 | POINTER | 1927.41 | This is the WEIGHT BEARING CAPABILITY from the last assessment or reassessment | |
263 | bilateral upper ext strength | 260;4 | BOOLEAN | 1:YES 0:NO | This is the BILATERAL UPPER EXT STRENGTH from the last assessment or reassessment | |
264 | applic cond to affect transfer | 260;5 | FREE TEXT | This is the APPLIC COND TO AFFECT TRANSFER from the last assessment or reassessment | ||
265 | katz score | 260;6 | NUMERIC | This is the KATZ SCORE from the last assessment or reassessment | ||
266 | decrease in independence | 260;7 | POINTER | 1927.41 | Was there a decrease in the patient's level of independence in the last 30 days? | |
267 | assist patient with | 260;8 | FREE TEXT | Functional items that the patient should be assisted with. Ambulating, bathing, etc. | ||
270 | bowel pattern | 270;1 | POINTER | 1927.41 | The patient's last bowel pattern. | |
271 | gi device types | 270;2 | FREE TEXT | Any devices in the patient's GI system. | ||
272 | special food preferences | 270;3 | BOOLEAN | 1:YES 0:NO | Does the patient have any special food preferences? | |
273 | nutrition description | 270;4 | POINTER | 1927.41 | How the patient looks, from a nutition point of view. | |
274 | appetite | 270;5 | FREE TEXT | The patient's appetite. | ||
275 | dysphagia screen | 270;6 | POINTER | 1927.41 | Patient's last Dysphagia screen results (able or not to screen). | |
275.1 | tbi | 270;7 | BOOLEAN | 1:YES 0:NO | Diagnosis of new Traumatic Brain Injury? | |
275.2 | modified texture diet | 270;8 | BOOLEAN | 1:YES 0:NO | Does the patient need a Modified Texture Diet? | |
275.3 | unable to follow commands | 270;9 | BOOLEAN | 1:YES 0:NO | Is the patient unable to follow commands? | |
275.4 | wet gurgly voice | 270;10 | BOOLEAN | 1:YES 0:NO | Does the patient have a wet gurgly voice? | |
275.5 | drooling while awake | 270;11 | BOOLEAN | 1:YES 0:NO | Is the patient drooling while they're awake? | |
275.6 | tongue deviation from midline | 270;12 | BOOLEAN | 1:YES 0:NO | Is the patient's tongue deviating from midline? | |
276 | unintentional weight loss/gain | 270;13 | SET OF CODES | 1:YES 0:NO 2:Unknown | Did the patient have an unintentional weight loss or gain in the last month? | |
277 | gi history | 270;14 | FREE TEXT | The GI problems that this patient has had. | ||
277.1 | gi other history | 277.1;0 | WORD-PROCESSING | |||
278 | abdominal assessment | 271;1 | FREE TEXT | The abdominal assessment on the patient. | ||
278.1 | other abdominal assessment | 278.1;0 | WORD-PROCESSING | |||
280 | musc history | 280;1 | FREE TEXT | The Musculoskeletal history of the patient. | ||
280.1 | other musc history | 280.1;0 | WORD-PROCESSING | |||
281 | range of motion | 280;2 | FREE TEXT | The patient's Range of Motion. | ||
290 | skin history | 290;1 | FREE TEXT | The patient's skin history | ||
291 | skin risk factors | 290;2 | FREE TEXT | The patient's skin risk factors. | ||
292 | skin patient ed provided | 290;3 | FREE TEXT | Was education provided to the patient or caregiver about skin care? | ||
293 | skin breakdown factors | 290;4 | FREE TEXT | The Skin Beakdown Factors that this patient has. | ||
300 | respiratory pattern | 300;1 | FREE TEXT | The patient's prior respiratory pattern. | ||
301 | work of breathing | 300;2 | FREE TEXT | The patient's prior Work of Breathing. | ||
302 | crackels/rales | 300;3 | FREE TEXT | The patient's prior Crackles & Rales (breath sounds). | ||
302.1 | diminished/decrased | 300;4 | FREE TEXT | The patient's prior Decreased/Diminshed Breath Sounds. | ||
302.2 | rhonchi | 300;5 | FREE TEXT | The patient's prior Rhonchi breath sounds. | ||
303 | sputum amount | 300;6 | POINTER | 1927.41 | The patient's prior amount of sputum. | |
303.1 | sputum color | 300;7 | FREE TEXT | The patient's prior sputum color. | ||
303.2 | sputum consistency | 300;8 | FREE TEXT | The patient's prior sputum consistency. | ||
304 | chaplain consult sent | 304;1 | BOOLEAN | 1:YES 0:NO | Was a Chaplain consult sent as part of this care plan from either the Admission Assessment or a prior reassessment? | |
304.1 | dp consult sent | 304;2 | BOOLEAN | 1:YES 0:NO | Was a DP consult sent as part of this care plan from either the Admission Assessment or a prior reassessment? | |
304.2 | nutrition consult sent | 304;3 | BOOLEAN | 1:YES 0:NO | Was a Nutrition consult sent as part of this care plan from either the Admission Assessment or a prior reassessment? | |
304.3 | speech consult sent | 304;4 | BOOLEAN | 1:YES 0:NO | Was a Speech consult sent as part of this care plan from either the Admission Assessment or a prior reassessment? | |
304.4 | social work consult sent | 304;5 | BOOLEAN | 1:YES 0:NO | Was a Social Work consult sent as part of this care plan from either the Admission Assessment or a prior reassessment? |