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