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Chapter 17 Planning person-centred care
PATIENT NAME: MRN: DOB:
Date:
Date:
Date:
am pm nd am pm nd am pm nd
Investigations
Mental status
Alert
Orientated
CAM score
Drowsy
required if not
Confused
alert and
Unconscious
orientated
Resistive to care, aggressive or agitated
Complete CAM score, record in the box
Assessment
Frequency
Day 1
Day 2
Day 3
TPR & BP
GMR
SpO
2
CIWA-AR
GCS
U/A
Other
Daily weigh (record kg daily) in the box
Mobility activity Identify level of assistance required for transfers
(Refer to Mobility Status chart)
Record falls risk score daily & PRN
Record postural BP if not attended O/A
Nutrition,
NBM
hydration & IV therapy: ensure cannula removed
Resite due:
IV therapy
Cannula score
Special/normal diet Red or Blue alert
Ensure diet flip chart correct
Fluid restriction
Circle NG /PEG/TPN rate
Skin integrity
Record Norton score once daily in square
Pressure area sticker in AM shift report
Pressure area care required:
Hygiene / ADL’s Independent
Full sponge
Refer to
Assist sponge
mobility chart
Full shower chair
Assist shower
Full bath with trolley bath
Mouth & eye care required
Elimination
Patient continent
Patient incontinent Urine
Patient incontinent Faeces
Chart bowels daily (each shift) on stool chart
Communication Speech Normal Slurred
Dysphasic Aphasic
Assist with communication aids if speech difficulties present
Education
Commence education for patients & carers
Discharge planning Advise person/family of discharge destination
& approx date, commence interagency forms/
planning for home adjustments as needed/
planning for transport home
Special needs &
O
2
rate & device:
technical activities
TPR (temperature, pulse, respirations), BP (blood pressure), GMR (glucometer reading), SpO
2
(oxygen saturation), CIWA-AR (alcohol withdrawal scale),
GCS (Glasgow Coma Scale), U/A (urinalysis), NG (nasogastric), PEG (percutaneous endoscopic gastrostomy), TPN (total parenteral nutrition).
See Appendix C for a list of abbreviations commonly used in healthcare facilities.
Figure 17-3
Example of a care map
