State Operated Community Program
SOCP Nurse Tools: http://www.dhs.state.or.us/spd/tools/dd/socp/nurses.html
SOCP Eliot Group Home – Nursing Assessment and Plan
Client name: / DOB: / House: / Annual
ISP date:
Subjective description:
Explain:
Primary diagnosis:
Explain:
Secondary diagnosis:
Explain:
Code status:
Explain:
Exams: most current / upcoming
Physical:
Labs:
Eye:
Mammogram:
/ Psych.:
Dental:
Hearing:
Pap/pelvic:
/ Pulmonary
Neurology
Cardiac:
Podiatry:
List all current medications
/Current medications / Dosage / Reason /
List all current treatments
/Current medications / Dosage / Reason /
List all current PRN to include - Self administered medications
/Current medications / Dosage / Reason /
Immunizations Records
Polio / Mumps / German Measles/Rubella / Chickenpox/Varicella
Measles / Rubeola / Diptheria / Tetanus (lockjaw) / Whooping Cough (Pertussis)
Haemophilus typeB (Hib) / Hepatitis B / Hepatitis A / Other:
Polio
Systems / number Was plan initiate: / Yes / No / Systems / number Was plan initiate: / Yes / No
H1 – Skin / scalp / H14,H15 /Allergies/adverse drug reactions
H2, H3, H4 / Orthopedic / Mobility / H16 / Nutrition / Hydration
H5 / Dental / H17 / Chewing / Swallowing
H6 / Eyes and Vision / H18 / Bowels
H7 / Ears and hearing / H19 / Stomach / Intestines
H8 / Respiratory / H20 / Hematology / Lymphatic
H9 / Injury / H21 / Urogenital
H10, H11 / Neurology/Seizures / H22 / Endocrine
H12 / Behaviors / H23 / Other
H13 / Cardiac / Vascular
Systems review / History / Subjective / Objective
H1: Skin / scalp / Problem(s):
At risk for:
Interventions:
Interval history
Current status:
Recommendations:
H2, H3, H4:
Orthopedic / Mobility / Problem(s):
At risk for:
Interventions:
Interval history
Current status:
Recommendations:
H5: Dental / Problem(s):
At risk for:
Interventions:
Interval history
Current status:
Recommendations:
H6: Eyes and Vision / Problem(s):
At risk for:
Interventions:
Interval history
Current status:
Recommendations:
H7: Ears and hearing / Problem(s):
At risk for:
Interventions:
Interval history
Current status:
Recommendations:
H8: Respiratory / Problem(s):
At risk for:
Interventions:
Interval history
Current status:
Recommendations:
H9: Injury / Problem(s):
At risk for:
Interventions:
Interval history
Current status:
Recommendations:
H10, H11: Neurology/Seizures / Problem(s):
At risk for:
Interventions:
Interval history
Current status:
Recommendations:
H12: Behaviors / Problem(s):
At risk for:
Interventions:
Interval history
Current status:
Recommendations:
H13: Cardiac / Vascular / Problem(s):
At risk for:
Interventions:
Interval history
Current status:
Recommendations:
H14,H15: Allergies/adverse drug reactions / Problem(s):
At risk for:
Interventions:
Interval history
Current status:
Recommendations:
H16: Nutrition / Hydration / Problem(s):
At risk for:
Interventions:
Interval history
Current status:
Recommendations:
H17: Chewing / Swallowing / Problem(s):
At risk for:
Interventions:
Interval history
Current status:
Recommendations:
H18:
Bowels / Elimination / Problem(s):
At risk for:
Interventions:
Interval history
Current status:
Recommendations:
H19:
Stomach / Intestines / Problem(s):
At risk for:
Interventions:
Interval history
Current status:
Recommendations:
H20: Hematology / Lymphatic / Problem(s):
At risk for:
Interventions:
Interval history
Current status:
Recommendations:
H21: Urogenital / Problem(s):
At risk for:
Interventions:
Interval history
Current status:
Recommendations:
H22: Endocrine / Problem(s):
At risk for:
Interventions:
Interval history
Current status:
Recommendations:
H23: Other / Problem(s):
At risk for:
Interventions:
Interval history
Current status:
Recommendations:
SOCP_ Eliot Nurse Care Plan.doc Page 1 of 6 TOOL (02/12)
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RN name (print): / Date:
RN signature: / Date:
signature
SOCP_ Eliot Nurse Care Plan.doc Page 1 of 6 TOOL (02/12)