Name______DOB______UW#______LAST REVISION______

ELECTRONIC MEDICAL HOME CARE PLAN

EMERGENCY CARE PLAN11/3/

Date Created: / SPECIAL NOTES
I like to be called
Primary MD / The language I use:
I like eye contact: YES NO
Address / I can be touched: YES NO
I am: Non-Verbal Deaf Blind
Phone: / Communication Aides:
FAX: / I like it best when you:
Primary Diagnosis:______ / Language age level: / Receptive: / Expressive:
Participate in decisions about health care:
Comments: / YES NO
Family Contact:
Patient lives with:
Relationship:
Address:
Telephone:(H)
(W)
(C)
Health Insurance Plan ID# / Emergency Contact:
Name:
Relationship:
Address:
Telephone(H)
(W)
(C)

Custody or other restrictions: Guardianship Power of Attorney Other

Comments:

Emergency Contact person:
Code Status: Advance directives exist Y N Comments:

Medical release for:

School: Yes NoWork: Yes NoHome Health Agency: Yes No

PE Findings/ Special Family Needs/Requests (ex., Communication or Transportation needs)

PERTINENT EMERGENCY HISTORY/ PHYSICIAN DATA
(Ex. BP Difficult to measure; Preemie/Wt.; Car Accident/date)
OTHER Comments:
CurrentVital Signs (baselines) Pertinent Physical Exam Findings Date:
Ht / Wt / Pulse / Rhythm
Resp / Oximetry / BP / Other
Blood Disorders: None HIV HBV HCV Hemophilia Other
BRIEF PERTINENT HISTORY
Snapshot for unfamiliar providers / Specialist
PhonePager#
/
CPT Code

MEDICATIONS

Allergies/Reaction: / Date of Onset
Latex/Reaction: / Date of Onset
Medications / Dose/Frequency / Route of administration / Date prescribed / Last drug level/INR’s
Complementary Therapy (e.g., Acupuncture, Chiropractor, Herbal Medications)

NUTRITION ISSUES

Allergies/Reactions ______Date of Onset: ______
Feeding Route: oral nasogastric tube gastrostomy tube jejunostomy tube
fundoplication

COMPREHENSIVE CARE PLAN

Challenges (please check all that apply and explain on lines below)

Behavioral / Learning / Hearing / Vision
Communication / Sensory / Neurologic / Stamina/Fatigue
Physical Anomalies / Respiratory / Cardiac / Feed/GI
Genitourinary / Orthopedic Musculo-Skeletal / Endocrine
Blood / Dental / Skin Integrity / Other

Comments:

CHRONIC DISEASE MANAGEMENT

Sequential Laboratory & Vital Signs

Vital Signs
BP
HGBAIC
Med Levels
INR

IMMUNIZATIONS:

Type / Date

HOSPITALIZATIONS (most recent listed first)

Primary Diagnosis / Location / Date

SKILLED NURSING FACILITY

Primary Diagnosis / Location / Date

PROCEDURES (most recent listed first)

Type / Location / Date

Comments:

DEVICES/EQUIPMENT:

Type / Date / Size / Supplier

Comments:

DEVELOPMENTAL/ACADEMIC TESTING:

THERAPY (OT, PT, SLP, Respiratory):

Type of Therapist / Frequency / Intensity / Duration / Location

SCHOOL/COMMUNITY SERVICES (includes early intervention/current school)

Type / Where/by Whom / Result

HOME HEALTH

Company:

Contact Person:
Phone/Fax/Beeper:

Type:

eligible hrs/wk:

actual hrs/wk:

Comments:

DURABLE MEDICAL EQUIPMENT

Company:

Contact Person:
Phone/Fax/Beeper:

Type:

SOCIAL WORKER

Name:

Agency:

Phone/Fax/Beeper:

BEHAVIORAL HEALTH:

Provider/Credential:

Location:

Phone/Fax/Beeper:

RESPITE:

Name:

Address:

Phone:

ACTIVE REFERRALS

Active Referral Type: / Dates of Service / Number of Visits Used / Number of Visits Allocated
DAILY CARE TEMPLATE
Cares / AM / PM / EVENING
Hygiene
Meds
Nutrition
Special Line Cares:
IV
Trach
Urinary Catheter
Feeding tube
Type:
Colostomy
Other Special Line Cares
Braces
Assistive Technology
Other

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Name______DOB______UW#______LAST REVISION______

DIAGNOSIS______

Ongoing Medical Issues / Date of onset / Assessment / Plan of Action / Person responsible / Date reviewed
1.
2.
3.
4.
5.
6.
SIGNED:
DATE:
Parent (s)/Patient
DATE:
MD

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