Patient Plan of Care & Medication Profile.

Patient Plan of Care

Used to update patient EMR (electronic medical record). Provide precise details.
Select the Correct Statement

Return Visit
Medical Record Number:
MRN
MRN:*
Todays Date:

MonthDayYear
(Current Date)
Time in: (keep at the 15 minute mark.)

(Arrival to client’s home/infusion suite)
🧾 Patient Summary

Comprehensive Medical Overview

Patient:
{patientLast}, {patientFirst}

DOB:
{dob727}

MRN:
{MRN}

Gender:
{gender}

Weight:
{patientWeight}

Height:
{height}

Patient Address:
{patientsAddress518} {patientAddress}

Pharmacy:
{pharmacyName}

🩺 Clinical Information

Primary Diagnosis:
{primaryDiagnosis}

ICD-10:
{icd10Code22}

Known Allergies:
{patientAllergies}

💉 Infusion Orders

Medication:
{medsubq} {medicationbrandIV}

Dose:
{totalDose}{gmmg}

Volume:
{volumeml289}

Frequency:
{repeatMaintenance}

Max Rate:
{maxRate1161}

{consecutively}

💊 Premedications

1. {premedication1}

2. {premedication2}

3. {premedication3}

4. {premedication4}

🚰 Hydration Orders

Pre-hydration:
{nsPrehydration}

Post-hydration:
{nsPosthydration}

🧪 Laboratory Orders

{areLabs}

{listSpecificLabs}

👨‍⚕️ Prescriber Information

Provider:
{prescribingMd}

Practice Address:
{patientsAddress440}
{city441}, {state442} {zipCode443}

Phone:
{phone}

Fax:
{fax}
Review the above Patient Info Before Proceeding

Do not leave any data blank or incorrect.
Ready to Proceed with Verified Patient Information?

YES - Everything Is Correct – There is NO missing data - Proceed to Medication ProfileNO - Information is Missing / Needs to be Added -or- Corrected – Edit Demographics

Medication Profile
Changes to the MEDICATION PROFILE?

YES*No Medication Changes

List all prescriptions, OTC, herbal, & home remedies.

	Start_Date	NAME_Prescription_OTC_herbal_Home_Remedy	Dosage_(Eg,.650mg)	Frequency_(Daily,AC,PC,PRN,etc...),	Route_of_admin	Stop_Date	Status:
Med #1
Med #2
Med #3
Med #4
Med #5
Med #6
Med #7
Med #8
Med #9
Med #10
Med #11
Med #12
Med #13
Med #14
Med #15
Med #16
Med #17
Med #18
Med #19
Med #20
Med #21
Med #22
Med #23
Med #24
Med #25
Med #26
Med #27
Med #28
Med #29
Med #30
Med #31
Med #32
Med #33
Med #34
Med #35
Med #36
Med #37
Med #38
Med #39
Med #40
Med #41
Med #42
Med #43
Med #44
Med #45
Med #46
Med #47
Med #48
Med #49
Med #50

Start Date Med #1
Medication #1
(Med #1)
Dose #1
(Med #1)
Frequency #1
(Med #1)
Route #1
(Med #1)
End Date Med #1
Status Med#1
Start Date Med #2
Medication #2
(Med #2)
Dose #2
(Med #2)
Frequency #2
(Med #2)
Route #2
(Med #2)
End Date Med #2
Status Med#2
Start Date Med #3
Medication #3
Dose #3
Frequency #3
Route #3
End Date Med #3
Status Med#3
Start Date Med #4
Medication #4
(Med #4)
Dose #4
Frequency #4
Route #4
End Date Med #4
Status Med#4
Start Date Med #5
Medication #5
Dose #5
Frequency #5
Route #5
End Date Med #5
Status Med#5
Start Date Med #6
Medication #6
(Med #6)
Dose #6
Frequency #6
Route #6
End Date Med #6
Status Med#6
Start Date Med #7
Medication #7
(Med #7)
Dose #7
Frequency #7
Route #7
End Date Med #7
Status Med#7
Start Date Med #8
Medication #8
Dose #8
Frequency #8
Route #8
End Date Med #8
Status Med#8
Start Date Med #9
Medication #9
Dose #9
Frequency #9
Route #9
End Date Med #9
Status Med#9
Start Date Med #10
Medication #10
(Med #10)
Dose #10
Frequency #10
(Med #10)
Route #10
(Med #10)
End Date Med #10
Status Med#10
Start Date Med #11
Medication #11
(Med #11)
Dose #11
(Med #11)
Frequency #11
(Med #11)
Route #11
(Med #11)
End Date Med #11
Status Med#11
Start Date Med #12
Medication #12
(Med #12)
Dose #12
(Med #12)
Frequency #12
(Med #12)
Route #12
(Med #12)
End Date Med #12
Status Med#12
Start Date Med #13
Medication #13
(Med #13)
Dose-#13
(Med #13)
Frequency #13
(Med #13)
Route #13
(Med #13)
End Date Med #13
Status Med#13
Start Date Med #14
Medication #14
(Med #14)
Dose #14
(Med #14)
Frequency #14
(Med #14)
Route #14
(Med #14)
End Date Med #14
Status Med#14
Start Date Med #15
Medication #15
(Med #15)
Dose #15
(Med #15)
Frequency #15
(Med #15)
Route #15
(Med #15)
End Date Med #15
Status Med#15
Start Date Med #16
Medication #16
(Med #16)
Dose #16
(Med #16)
Frequency #16
(Med #16)
Route #16
(Med #16)
End Date Med #16
Status Med#16
Start Date Med #17
Medication #17
(Med #17)
Dose #17
(Med #17)
Frequency #17
(Med #17)
Route #17
(Med #17)
End Date Med #17
Status Med#17
Start Date Med #18
Medication #18
(Med #18)
Dose #18
(Med #18)
Frequency #18
(Med #18)
Route #18
(Med #18)
End Date Med #18
Status Med#18
Start Date Med #19
Medication #19
(Med #19)
Dose #19
(Med #19)
Frequency #19
(Med #19)
Route #19
(Med #19)
End Date Med #19
Status Med#19
Start Date Med #20
Medication #20
(Med #20)
Dose #20
(Med #20)
Frequency #20
(Med #20)
Route #20
(Med #20)
End Date Med #20
Status Med#20
Start Date Med #21
Medication #21
(Med #21)
Dose #21
(Med #21)
Frequency #21
(Med #21)
Route #21
(Med #21)
End Date Med #21
Status Med#21
Start Date Med #22
Medication #22
(Med #22)
Dose #22
(Med #22)
Frequency #22
(Med #22)
Route #22
(Med #22)
End Date Med #22
Status Med#22
Start Date Med #23
Medication #23
(Med #23)
Dose #23
(Med #23)
Frequency #23
(Med #23)
Route #23
(Med #23)
End Date Med #23
Status Med#23
Start Date Med #24
Medication #24
(Med #24)
Dose #24
(Med #24)
Frequency #24
(Med #24)
Route #24
(Med #24)
End Date Med #24
Status Med#24
Start Date Med #25
Medication #25
(Med #25)
Dose #25
(Med #25)
Frequency #25
(Med #25)
Route #25
(Med #25)
End Date Med #25
Status Med#25
Start Date Med #26
Medication #26
(Med #26)
Dose #26
(Med #6)
Frequency #26
(Med #26)
Route #26
(Med #26)
End Date Med #26
Status Med#26
Start Date Med #27
Medication #27
(Med #27)
Dose #27
(Med #27)
Frequency #27
(Med #27)
Route #27
(Med #27)
End Date Med #27
Status Med#27
Start Date Med #28
Medication #28
(Med #28)
Dose #28
(Med #28)
Frequency #28
(Med #28)
Route #28
(Med #28)
End Date Med #28
Status Med#28
Start Date Med #29
Medication #29
(Med #29)
Dose #29
(Med #29)
Frequency #29
(Med #29)
Route #29
(Med #29)
End Date Med #29
Status Med#29
Start Date Med #30
Medication #30
(Med #30)
Dose #30
ㅤ
Frequency #30
(Med #30)
Route #30
(Med #10)
End Date Med #30
Status Med#30
Start Date Med #31
Medication #31
(Med #31)
Dose #31
(Med #31)
Frequency #31
(Med #31)
Route #31
(Med #31)
End Date Med #31
Status Med#31
Start Date Med #32
Medication #32
(Med #32)
Dose #32
(Med #32)
Frequency #32
(Med #32)
Route #32
(Med #32)
End Date Med #32
Status Med#32
Start Date Med #33
Medication #33
(Med #33)
Dose #33
(Med #33)
Frequency #33
(Med #33)
Route #33
(Med #33)
End Date Med #33
Status Med#33
Start Date Med #34
Medication #34
(Med #34)
Dose #34
(Med #34)
Frequency #34
(Med #34)
Route #34
(Med #34)
End Date Med #34
Status Med#34
Start Date Med #35
Medication #35
(Med #35)
Dose #35
(Med #35)
Frequency #35
(Med #5)
Route #35
(Med #35)
End Date Med #35
Status Med#35
Start Date Med #36
Medication #36
(Med #36)
Dose #36
Frequency #36
Route #36
(Med #36)
End Date Med #36
Status Med#36
Start Date Med #37
Medication #37
Dose #37
(Med #37)
Frequency #37
(Med #37)
Route #37
(Med #37)
End Date Med #37
Status Med#37
Start Date Med #38
Medication #38
(Med #38)
Dose #38
(Med #38)
Frequency #38
(Med #38)
Route #38
(Med #8)
End Date Med #38
Status Med#38
Start Date Med #39
Medication #39
(Med #39)
Dose #39
(Med #39)
Frequency #39
(Med #39)
Route #39
(Med #39)
End Date Med #39
Status Med#39
Start Date Med #40
Medication #40
(Med #10)
Dose #40
Frequency #40
(Med #40)
Route #40
(Med #40)
End Date Med #40
Status Med#40
Start Date Med #41
Medication #41
(Med #41)
Dose #41
(Med #41)
Frequency #41
(Med #41)
Route #41
(Med #41)
End Date Med #41
Status Med#41
Start Date Med #42
Medication #42
(Med #42)
Dose #42
(Med #42)
Frequency #42
(Med #42)
Route #42
(Med #42)
End Date Med #42
Status Med#42
Start Date Med #43
Medication #43
(Med #43)
Dose #43
Frequency #43
Route #43
End Date Med #43
Status Med#43
Start Date Med #44
Medication #44
(Med #4)
Dose #44
Frequency #44
Route #44
End Date Med #44
Status Med#44
Start Date Med #45
Medication #45
(Med #45)
Dose #45
Frequency #45
Route #45
End Date Med #45
Status Med#45
Start Date Med #46
Medication #46
(Med #46)
Dose #46
Frequency #46
Route #46
End Date Med #46
Status Med#46
Start Date Med #47
Medication #47
(Med #47)
Dose #47
Frequency #47
Route #47
End Date Med #47
Status Med#47
Start Date Med #48
Medication #48
Dose #48
Frequency #48
Route #48
End Date Med #48
Status Med#48
Start Date Med #49
Medication #49
Dose #49
(Med #49)
Frequency #49
Route #49
End Date Med #49
Status Med#49
Start Date Med #50
Medication #50
(Med #50)
Dose #50
Frequency #50
(Med #50)
Route #50
(Med #50)
End Date Med #50
Status Med#50
Has the Medication Profile has been updated:

YES* (I have documented all medication changes)

Have there been changes made to this Re-Certification?

YES, MD Signature is Required.NO CHANGES MADE. MD signature is NOT required.
Is this Form Complete? (Have all required fields been completed)*

YESNO
Incomplete Submission Explanation
State what issue or condition stopped you from completing the form.
RN First Name:
RN Last Name:
(Nurse Last Name)
Title
RN, BSN
Are you the Primary RN for this client.

YES*NO
Primary RN:
(MAPPING)
RN Signature*
Date signed:

MonthDayYear
Date of signature (Todays date)
Workflow/boards-Document Name
Document Name
PDF Title:
Folder Name
URL info to push to the Nursng visit notes.

Realo

https://forms.mynursenotepro.com/252018389213960?MRN={MRN}&date224={date224}&patientFirst={patientFirst}&patientLast={patientLast}&dob727={dob727}&gender={gender}&pharmacyName={pharmacyName}¤tWeight={currentWeight}&height={height}&Knownallergies={Knownallergies}&patientAllergies={patientAllergies}&therapyOrdered18={therapyOrdered18}&medicationBrand={medicationBrand}&areLabs={areLabs}&listSpecificLabs={listSpecificLabs}&frequencyOf={frequencyOf}&ordersExpiration={ordersExpiration}&orderedPremedications={orderedPremedications}&premedication1={premedication1}&dosage={premed1}&routeOf={routeOf}&secondPremedication={secondPremedication}&premedication2={premedication2}&dosage487={dosage487}&routeOf490={routeOf490}&isA3rdpremedordered={isA3rdpremedordered}&premedication3={premedication3}&dosage488={dosage488}&routeOf491={routeOf491}&isTherePreHydrationOrders={isTherePreHydrationOrders}&orderedPreHydrationFluid={orderedPreHydrationFluid}&prehydrationVolume={prehydrationVolume}&prehydrationVolumemaxInfusionrate={prehydrationVolumemaxInfusionrate}&postinfusionHydrationorders={postinfusionHydrationorders}&orderedPosthydration={orderedPosthydration}&maxRateofPostHydration={maxRateofPostHydration}&posthydrationVolume={posthydrationVolume}&isHeparinOrdered={isHeparinOrdered}&patientCurrentOrders={patientCurrentOrders}&primaryinfusionmaxrate={primaryinfusionmaxrate}&previousVisitNOTES={previousVisitNOTES}&rnFirst={rnFirst}&rnLast={rnLast}&timeIn={timeIn}&gmmg={gmmg}&epiEXP={epiEXP}&ivDip={ivDip}&anahydro={anahydro}&isA={isA}&premed4={premed4}&premedication4={premedication4}&premed41154={premed41154}&4Route={4Route}&premed41156={premed41156}&folderName={folderName}&patientInitials={patientInitials}&changesTo={changesTo}

ICRx

https://forms.mynursenotepro.com/251354532606958?MRN={MRN}&date224={date224}&patientFirst={patientFirst}&patientLast={patientLast}&dob727={dob727}&gender={gender}&pharmacyName={pharmacyName}¤tWeight={currentWeight}&height={height}&Knownallergies={Knownallergies}&patientAllergies={patientAllergies}&therapyOrdered18={therapyOrdered18}&medicationBrand={medicationBrand}&areLabs={areLabs}&listSpecificLabs={listSpecificLabs}&frequencyOf={frequencyOf}&ordersExpiration={ordersExpiration}&orderedPremedications={orderedPremedications}&premedication1={premedication1}&dosage={premed1}&routeOf={routeOf}&secondPremedication={secondPremedication}&premedication2={premedication2}&dosage487={dosage487}&routeOf490={routeOf490}&isA3rdpremedordered={isA3rdpremedordered}&premedication3={premedication3}&dosage488={dosage488}&routeOf491={routeOf491}&isTherePreHydrationOrders={isTherePreHydrationOrders}&orderedPreHydrationFluid={orderedPreHydrationFluid}&prehydrationVolume={prehydrationVolume}&prehydrationVolumemaxInfusionrate={prehydrationVolumemaxInfusionrate}&postinfusionHydrationorders={postinfusionHydrationorders}&orderedPosthydration={orderedPosthydration}&maxRateofPostHydration={maxRateofPostHydration}&posthydrationVolume={posthydrationVolume}&isHeparinOrdered={isHeparinOrdered}&patientCurrentOrders={patientCurrentOrders}&primaryinfusionmaxrate={primaryinfusionmaxrate}&previousVisitNOTES={previousVisitNOTES}&rnFirst={rnFirst}&rnLast={rnLast}&timeIn={timeIn}&gmmg={gmmg}&epiEXP={epiEXP}&ivDip={ivDip}&anahydro={anahydro}&isA={isA}&premed4={premed4}&premedication4={premedication4}&premed41154={premed41154}&4Route={4Route}&premed41156={premed41156}&folderName={folderName}&patientInitials={patientInitials}&changesTo={changesTo}
POC_Last signed by MD on:
This is for the conditional logic to flag that it is time to get MD to sign
"Submit" to Continue to the required

{pharmacyName} Nursing Visit Notes.
"Submit" to Continue to the required Admission Packet.
Should be Empty:

Patient Plan of Care

🧾 Patient Summary

🩺 Clinical Information

💉 Infusion Orders

💊 Premedications

🚰 Hydration Orders

🧪 Laboratory Orders

👨‍⚕️ Prescriber Information

Review the above Patient Info Before Proceeding

Patient Demographics

Please Review and Correct Patient Details Below

Patients Home Address

Medical Diagnosis

Verification of Signed Orders

Infusion Cycle Parameters, and Frequency

Pre-Medications

Pre-Hydration Orders

Post-Hydration Orders

Labs (Bloodwork)

AIS-POC

Advanced Directives

Prescribing MD Information

Medication Profile

RN Signature*