Noncompliance
(_) Exercise (_) Follow-up Care (_) Medication (_) Other
| (_)
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:_____________________________ ____________________________________ ____________________________________ |
| 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:
(_) 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:
(_) Set goals with patient. (_) Consult with:
(_)
Other:________________ |
__________________________
Patient/Significant other signature
__________________________
RN signature
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