File NUPA_CARE_PLANS(1927.4) Data List

DATE/TIME ENTERED	PATIENT	SUSPECTED VICTIM OF ABUSE/NEGL	GEN INFO DONE	RESP DONE	CV DONE	NEURO DONE	GI DONE	GU DONE	MS DONE	SKIN DONE	PS DONE	ORGAN DONOR	MH DONE	FUNC DONE	DP DONE	REL PRACTICES FOR CHAPLAIN	IMMEDIATE CHAPLAIN VISIT	SHOULD CLERGY BE NOTIFIED	RECV INFO ON AD	INITIATE OR CHANGE AD	TEST FOR MRSA BROCHURE GIVEN	PATIENT AUTHORIZE NARES	NARES PREFORMED	INFECTION CONTROL ED PROVIDED	ALLERGY POINTER	PAIN LOCATION 1	PAIN TYPE 1	ONSET OF PAIN 1	PAIN WORSE 1	PAIN BETTER 1	AREAS OF LIFE 1	PAIN GOAL 1	OTHER PAIN REGION 1	PRECAUTIONS	PAIN LOCATION 2	PAIN TYPE 2	ONSET OF PAIN 2	PAIN WORSE 2	PAIN BETTER 2	AREAS OF LIFE 2	PAIN GOAL 2	OTHER PAIN REGION 2	LEVEL OF UNDERSTANDING	PAIN LOCATION 3	PAIN TYPE 3	ONSET OF PAIN 3	PAIN WORSE 3	PAIN BETTER 3	AREAS OF LIFE 3	PAIN GOAL 3	OTHER PAIN REGION 3	PAIN LOCATION 4	PAIN TYPE 4	ONSET OF PAIN 4	PAIN WORSE 4	PAIN BETTER 4	AREAS OF LIFE 4	PAIN GOAL 4	OTHER PAIN REGION 4	PAIN LOCATION 5	PAIN TYPE 5	ONSET OF PAIN 5	PAIN WORSE 5	PAIN BETTER 5	AREAS OF LIFE 5	PAIN GOAL 5	OTHER PAIN REGION 5	PRECAUTIONS (FLAGS)	ABILITY TO READ	ABILITY TO WRITE	EDUCATIONAL LEVEL	LATEST DNR NOTE	PERIPHERAL LINE 1 LOCATION	PERIPHERAL LINE 1 SIZE	PERIPHERAL LINE 1 DATE INS	PERIPHERAL LINE 2 LOCATION	PERIPHERAL LINE 2 SIZE	PERIPHERAL LINE 2 DATE INS	PERIPHERAL LINE 3 LOCATION	PERIPHERAL LINE 3 SIZE	PERIPHERAL LINE 3 DATE INS	WARD	CENTRAL LINE 1 TYPE	CENTRAL LINE 1 LOCATION	CENTRAL LINE 1 DATE INS	CENTRAL LINE 1 IMPREG	CENTRAL LINE 1 POWER INJ	CENTRAL LINE 2 TYPE	CENTRAL LINE 2 LOCATION	CENTRAL LINE 2 DATE INS	CENTRAL LINE 2 IMPREG	CENTRAL LINE 2 POWER INJ	CENTRAL LINE 3 TYPE	CENTRAL LINE 3 LOCATION	CENTRAL LINE 3 DATE INS	CENTRAL LINE 3 IMPREG	CENTRAL LINE 3 POWER INJ	ENTERED BY	ORIENTED	TRACH TYPE	OTHER TRACH TYPE	TRACH SIZE	TOBACCO SCREEN	RESP HISTORY	PRODUCTIVE COUGH	CHEST TUBE 1 LOCATION	CHEST TUBE 1 DATE INSERTED	CHEST TUBE 2 LOCATION	CHEST TUBE 2 DATE INSERTED	CHEST TUBE 3 LOCATION	CHEST TUBE 3 DATE INSERTED	CHEST TUBE 4 LOCATION	CHEST TUBE 4 DATE INSERTED	ABLE TO ASSESS EDUCATION	EDEMA-RIGHT ARM	EDEMA-LEFT ARM	EDEMA-RIGHT HAND	EDEMA-LEFT HAND	EDEMA-RIGHT LEG	EDEMA-LEFT LEG	EDEMA-PEDAL RIGHT	EDEMA-PEDAL LEFT	EDEMA-FACIAL	EDEMA-PERIORBITAL	EDEMA-SACRAL	EDEMA-RIGHT HIP	EDEMA-LEFT HIP	EXTREMITIES	EXTREMITIES COMMENTS	JUGULAR VENEOUS DISTORTION	HOMAN'S SIGN	CARDIAC MONITOR	CARDIAC RHYTHMS	CV HISTORY	OTHER CV HISTORY	LEARNS BEST BY	AUTONOMIC DYSREFLEXIA	ORIENTATION (MENTATION)	GLASGOW COMA SCALE SCORE	MOTOR-RIGHT ARM	MOTOR-LEFT ARM	MOTOR-RIGHT LEG	MOTOR-LEFT LEG	PUPIL SIZE	RIGHT EYE REACTIVITY	LEFT EYE REACTIVITY	SPEECH/LANGUAGE	SENSATIONS	PRIOR SENSATIONS	REQ ASSISTIVE COMM DEVICES	PRIOR COMMUNICATION DEVICES	LENS IMPLANTS	NEURO HISTORY	EDUCATION PREFERRED	INDWELLING CATHETER SIZE	INDWELLING CATHETER DATE INS	ABNORMAL DISCHARGE	PRIOR PREGNANCY	GU HISTORY	READINESS TO LEARN	ATTITUDE	BEHAVIOR	VERBAL ABUSE	PHYSICAL ABUSE	FINANCIAL ABUSE	RAPE OR SEXUAL ABUSE	NEGLECT	NA VERBAL ABUSE	NA PHYSICAL ABUSE	NA NEGLECT	NA HOUSEHOLD VICTIMS	THOUGHTS OF HARMING YOURSELF	PLAN	PLAN DESCRIPTION	MEANS AVAILABLE	MEANS DESCRIPTION	REHEARSED OR PRACTICED	HEARD VOICES	TRIED TO HURT YOURSELF	FEELING HOPELESS	HAS GUARDIAN	GUARDIAN NAME	LEGALLY COMMITTED	DANGER TO THEMSELF	ON LEGAL OBSERVATION	LACKS COGNITIVE ABILITY	HISTORY OF ESCAPE	HISTORY OF ESCAPE FROM WHERE	ALCOHOL USE	USE RECREATIONAL DRUGS	MEDICAL MARIJUANA CARD	CONTRABAND	PSYCHOSOCIAL HISTORY	BARRIERS TO LEARNING	BARRIERS TO LEARNING DESCRIP	WHAT MAKES PATIENT UPSET	OTHER MAKES PATIENT UPSET	HOW ACT WHEN LOSE CONTROL	OTHER LOSE CONTROL	PATIENT CALM THEMSELF	OTHER CALM THEMSELVES	MOOD	OTHER MOOD	AFFECT	OTHER AFFECT	OTHER BEHAVIOR	BEHAVIORAL HEALTH ADVANCED DIR	NOTIFY IF PLACED IN RESTRAINTS	WHO TO NOTIFY IF PLACED IN RES	MH HISTORY	OTHER MH HISTORY	SO ANGRY TO LOSE CONTROL	CALM THEMSELF	KNOWLEDGE OF CURRENT ILLNESS	LEVEL OF ASSISTANCE	LEVEL OF COOPERATION	WEIGHT BEARING CAPABILITY	BILATERAL UPPER EXT STRENGTH	APPLIC COND TO AFFECT TRANSFER	KATZ SCORE	DECREASE IN INDEPENDENCE	ASSIST PATIENT WITH	EDUCATIONAL INFO PROVIDED	BOWEL PATTERN	GI DEVICE TYPES	SPECIAL FOOD PREFERENCES	NUTRITION DESCRIPTION	APPETITE	DYSPHAGIA SCREEN	TBI	MODIFIED TEXTURE DIET	UNABLE TO FOLLOW COMMANDS	WET GURGLY VOICE	DROOLING WHILE AWAKE	TONGUE DEVIATION FROM MIDLINE	UNINTENTIONAL WEIGHT LOSS/GAIN	GI HISTORY	GI OTHER HISTORY	ABDOMINAL ASSESSMENT	OTHER ABDOMINAL ASSESSMENT	MUSC HISTORY	OTHER MUSC HISTORY	RANGE OF MOTION	SKIN HISTORY	SKIN RISK FACTORS	SKIN PATIENT ED PROVIDED	SKIN BREAKDOWN FACTORS	INTERVENTIONS	RESPIRATORY PATTERN	WORK OF BREATHING	CRACKELS/RALES	DIMINISHED/DECRASED	RHONCHI	SPUTUM AMOUNT	SPUTUM COLOR	SPUTUM CONSISTENCY	CHAPLAIN CONSULT SENT	DP CONSULT SENT	NUTRITION CONSULT SENT	SPEECH CONSULT SENT	SOCIAL WORK CONSULT SENT	PROBLEMS	PROBLEM COMMENTS	PRIMARY LANGUAGE	ACCOMPLISH BY THIS HOSP	DISCH TO HOME WO ADD SERVICES	DP GOALS	DP GOALS OTHER 1	DP GOALS OTHER 2	DP GOALS OTHER 3	BRADEN SCORE	BRADEN SCORE DATE	MORSE SCORE	MORSE SCORE DATE	FAMILY SUPPORT INVOLVED IN DP	DP OBSERVATIONS/COMMENTS	CULTURAL PRACTICES	CULTURAL PRACTICES DESCRIPTION	GENERAL OBSERVATIONS/COMMENTS	BLOOD TRANSFUSION CONCERNS	BLOOD TRANSFUSION DESCRIPTION	PROBLEM EVALUATIONS	INTERVENTION EVALUATION	ADVANCE DIRECTIVE	ADVANCE DIRECTIVE LOCATION	BED TO CHAIR	BED TO CHAIR STAFF	BED TO STRETCHER	BED TO STRETCHER STAFF	CHAIR TO STRETCHER	CHAIR TO STRETCHER STAFF	REPOS IN BED	REPOS IN BED STAFF	REPOS IN CHAIR	REPOS IN CHAIR STAFF	TRANSFER FROM FLOOR	TRANSFER FROM FLOOR STAFF	SLING TYPE	SLING SIZE	SPECIAL DIET NEEDS	SPECIAL DIET NEEDS DESCRIPTION