Care Plan Notes

Read the following Care Plan notes. Rewrite the notes to correct grammar, spelling, capitalization, and sentence structure. Remember the notes should be clear, concise, complete and correct. They should address the participant’s concern, what was addressed, the participant’s plan, and the follow up plan.

Original note / Edited note
Risk Condition: *Low Hemoglobin/Hematocrit
Intake: Inadequate vitamin/mineral intake
Intervention/Care Plan: condition currently managed appropriately
Comments: Low Hgb, States OB is aware of, Taking Prenatal Vit NE reinforced.Will follow the WIC’s nutritional meal plan.To be evaluated at next appt. / Participant’s concern: low hemoglobin
What was discussed: Doctor aware
Participant’s plan: continue prenatal vitamin and follow WIC meal plan
Follow up plan: Evaluate next appointment
Risk: Underweight/At risk of underweight
Intake: Increased Nutrient Needs
Intervention/Care Plan: CPA Recommendation
Comments: Discussed ways to increase calories. Mom is slim. Will follow up in 2mths for wt check.(Wt for Ht has crossed two major growth percentiles and is now below the 10% - Colleen Pierre) / Participant’s concern: underweight
What was discussed: ways to increase calories
Participant’s plan:
Follow up plan: Follow up in 2 months for weight check
Risk condition: asthma, Moderate or Severe Persistent, Underweight/At Risk of Underweight
Intake: increased nutrient needs
Clinical: Underweight
Intervention/CarePlan: Condition currently managed appropriately
Comments: CHILD’S WEIGHT IS STILL LOW. FLOVENT IS USED PRN AND CHILD IS BEING FOLLOWED BY HEALTH CARE PROVIDER. / Participant’s concern: child’s underweight
What was discussed:
Participant’s plan:
Follow up plan:
Risk Condition: Diabetes Mellitus
Clinical: Altered nutrition-related laboratory values
Intervention/Care Plan: Referral to RD with special expertise
Comments: MS. SMITH STATESTHAT SHE WAS DX WITH DM IN FEB 2010, THAT SHE TOOK MEDS FROM FEB-JUNE 2010, THAT MEDS WERE DISCONTINUED AFTER LOSING 15 LBS. SINCE, DIABETES HAS BEEN CONTROLLED BY DIET ALONE. STATES TO CHECK BLOOD SUGAR X4 DAILY AND THAT SHE NEEDS TO CONTACT DCP IF PROBLEMS ARISE.
BREASTFEEDING EXCLUSIVELY, HGB 10.6, WT 191
SEEMS TO REALLY ENJOY BF’ING
DOES NOT ALWAYS EAT B’FAST AND SNACKS
DISCUSSED HEALTH TIPS FOR NEW MOMS, MEAL PATERN AND WHO NEEDS IRON.
NC APPT 6/22/2010 / Participant’s Concern:
What was discussed: health tips for new moms, meal pattern, and who needs iron
Participant’s plan:
Follow up plan: Nutrition Care appointment