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Noncompliance

Noncompliance

(_) Exercise (_) Follow-up Care (_) Medication (_) Other

Related To:
[Check those that apply]
(_) Chronic illness
(_) Fatigue
(_) Depression
(_) Non supportive family
(_) Inadequate/incomplete instructions
(_) Denial of Dx
(_) Side effects of therapy/med
(_) Impaired ability to perform tasks
(_) Expensive therapy
(_) Other:_____________________________
____________________________________
____________________________________

 

As evidenced by:
[Check those that apply]
Major:
(
Must be present)
(_) Verbalization of non-compliance or non-participation or confusion about thrapy and/or
(_) Direct observation of behavior indicating non-compliance
Minor:
(
May be present)
(_) Missed appointments (_) Partially used or unused medications
(_) Progression of disease process. (_) Persistance of symptoms

 

Date &
Sign.
Plan and Outcome
[Check those that apply]
Target
Date:
Nursing Interventions
[Check those that apply]
Date
Achieved:
  The patient will:

(_) Demonstrate compliance with:

 

 

(_) Other:

  (_) Assess patient's:
  • Understanding of disease process
  • Barriers to compliance
  • Life-style
  • Support system
  • Perception of non-compliance
  • Other:

(_) Allow patient and s/o to verbalize feelings about situation/

(_) Adapt regime to patient's level of comprehension.

(_) Involve patient - s/o in planning compliance.

(_) Emphasize positive aspects of compliance.

(_) Instruct patient - s/o about meds:

  • Side effects
  • Dosage
  • Other:

(_) Set goals with patient.

(_) Consult with:

  • PT
  • OT
  • Home Health
  • Social Services

(_) Other:________________
________________________
________________________
________________________

 

 

__________________________
Patient/Significant other signature

 

__________________________
RN signature