Clinical Communication Tool

Clinical Communication Tool

I. Patient Information

Patient Name: Allene Tillman
Date of Birth: January 15, 1975
Admission Date: March 5, 2050
Diagnosis: Congestive Heart Failure

II. Goals of Care

Short-Term Goals

  1. Fluid Management

    • Goal: Reduce fluid retention to a safe level within the next 48 hours.

    • Measurable Objective: Monitor daily weight; aim for a weight loss of 2-3 pounds within the next 2 days.

  2. Symptom Relief

    • Goal: Achieve relief from shortness of breath during activities.

    • Measurable Objective: The patient reports a decrease in dyspnea to a level of 2 or less on a scale of 0-10 within 24 hours.

Long-Term Goals

  1. Lifestyle Modification

    • Goal: Educate the patient on heart-healthy diet changes by the discharge date.

    • Measurable Objective: The patient will verbalize at least three dietary modifications to make by discharge.

  2. Medication Adherence

    • Goal: Ensure the patient understands medication regimen and its importance.

    • Measurable Objective: Patient demonstrates correct understanding of medications, including dosage and timing, before discharge.

III. Care Plan and Interventions

Nursing Interventions

Intervention

Frequency

Responsible Nurse

Assess vital signs

Every 4 hours

[Your Name]

Monitor intake and output

Daily

[Your Name]

Administer diuretics as prescribed

As per physician order

[Your Name]

Provide education on dietary restrictions

Daily during meals

[Your Name]

Multidisciplinary Team Collaboration

Team Member

Role

Contact Information

Dr. Emie Howell

Attending Physician

emie@you.mail

Tracey Gleason

Nurse

tracey@you.mail

Kitty Johns

Nurse

kitty@you.mail

Adelia Harber

Nurse

adelia@you.mail

IV. Patient and Family Involvement

Education Plan

  • Discuss heart failure and its implications.

  • Provide written material on heart-healthy living.

  • Schedule a follow-up appointment within one week of discharge.

Family Engagement

  • Encourage family participation in education sessions.

  • Provide resources for support groups.

V. Evaluation

Evaluation Criteria

  1. Fluid Management:

    • Patient weight will decrease by 2-3 pounds.

  2. Symptom Relief:

    • Patient reports decreased shortness of breath.

  3. Lifestyle Modification:

    • Patient can articulate dietary changes.

  4. Medication Adherence:

    • Patient accurately describes medication regimen.

For further information or inquiries, please feel free to reach out to me, [Your Name], at [Your Email]. You can also contact [Your Company Name] at [Your Company Email]. We are located at [Your Company Address], and our contact number is [Your Company Number].

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