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FROM ST. JOE GAS & BAIT FAX NO. : 12185687272 Jun. 04 2006 08:03PM P4 <br /> IVAI I uvnio�v . <br /> DISCHARGE ASSESSMENT/iNSTRUCTT0NS MRN: 21-53-72 DR:MILLOY.PAU <br /> S To be completed by Nursing L.. 5W5o15M ADM:08131/200 <br /> PAGE DOB:O ItI949 56Y SEk F (218)S58-5811 <br /> Ewe. R Fin#:7518775 r <br /> 218-829-2861 M���p1I11�W1 tl�lll �99�IA�11 <br /> Medication Dose Fr uene , <br /> *P=:Educational sheets given.and explained p•ia'prmeription.given,not.filled <br /> Pwfer.to attached af:. <br /> 'tine Calendalr ;MAR No:Medications " <br /> Diet)D' R eHospitalization: `IT n .. N/A <br /> Discharge Diet order: Dietician Consult Date: <br /> physician A.ctivityww- -.. <br /> •••. ,�,_,:_. �., Follow-up <br /> eaith>Educat'ion':Surnmar,Y,`.�: ::• ezbalizgs� - " EducationRe£erral <br /> 'nom ' 'C`omfiierits' <br /> Diagnosis :Yes•❑No•❑N/A ;. .. <br /> Medication7Asin Medicafion o❑N/A <br /> Potential DrUVFoad•Inuraction• Yes❑No❑N/A <br /> :Poteatia'Dlnt rugTnteraction .•es'�p❑ i/A <br /> Nutritiozi :es_❑No❑N/ <br /> Oral Health ❑Yes❑Na: /A <br /> Activity/Safety ' es:❑N�H- <br /> .0NEquipUae ❑Yes;.❑No /1 <br /> . Rehab'Techniquies' .DYeS'�No <br /> Self CarelGrrooniittg Yes DNo /A _ <br /> Coaanuaity Resources :❑Yea•❑No �A - <br /> Other. ❑Yes❑No A <br /> A •t r .• <br /> Instruction for.Cnre: �` -1 <br /> JOE <br /> ILL <br /> �.. f <br /> r <br /> Physician a Card.evn ' ❑Yes [3 NIA <br /> Patientwill make own appointment: SZYes ❑N/A <br /> Supplies/equipmew given or has:at home: ,[i�N/A <br /> Patient/fh,uuy bas uo further question regarding discharge instructions at this tune: ❑No ❑Yes <br /> Comments: <br /> v1i]4jes;iu'Saf No ,❑Yes-'Returned toTatient/family;d; es•To_ahom: <br /> TimeJDate o1•Release: TInut <br /> Patient's Signature: ate: <br /> Original to Chart/ Mt!e eferring Facility Yes Given-to: <br /> RN Signature: `. 'PN Signature: Date: <br /> ' +, <br /> . . _.. . <br /> 10104 <br />