Manual: Provision of Care, Treatment and Services Manual (Ver 3) External Reference: "(TJC PC.01.02.01, PC.01.02.03, PC.01.02.05)"
This customizable document, 12 - 21 Years, is taken from MCN Healthcare's Provision of Care, Treatment and Services Manual. For more than 20 years, MCN has been the health care industry's leading provider of policy and procedure templates, forms, competencies and other compliance tools. MCN provides more than 80 health care specific policy and procedure manuals for Acute Care Hospitals, Ambulatory Care, Behavioral Health, Home Health, Physician Practice, and Long Term Care. MCN's policy and procedure manuals focus on the latest healthcare "hot topic" issues related to patient safety and prevention of medical healthcare errors. Here is some sample content from 12 - 21 Years:
| | PEDIATRIC ASSESSMENT
12 - 21 Years
Patient Name:
Admission Date:
Vital Statistics
Height:
Pulse:
Mode of Transport:
Guardian Name and Relationship:
Home Phone:
Language Spoken: Patient:
Orientation to Patient Room/Unit
? Call Light
? Meals
? Typical Day in Hospital
Diagnosis:
Patient States Presence of Pain:
If yes, list location of pain:
Non-verbal Patient Exhibiting Symptoms of Pain:
If yes, list symptoms and location:
Comprehensive Pain Assessment to be completed as addendum for all patients presenting with pain
Patient's/Family's Concept of Reason for Hospitalization:... |
| Second excerpt: |
| | ...to accept blood in case of emergency:
Reason:
REVIEW OF SYSTEMS Check all appropriate items
1.
Head:
Scalp:
Vision:
No problems Glasses/contacts Blurring Headaches Diplopia Inflammation Cataracts Glaucoma Puffy lids Jaundice scleraPupils:
Hearing:
No problems Limited Pain Ringing Tubes Hearing Aid Feeling of Fullness Discharge Other:
Neck:
Lymph nodes Stiffness PainComments:
Throat:
Color:
Speech:
Clear Slurred Non-English speaking Can understand Can express ... |
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