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FROM : ST. JOE GAS & BAIT FAX N0. : 12185687272 Jun. 04 2006 08:05PM P8 <br /> MAN: 21-53-72 DR:HOWAR0,Jos <br /> DISCFIA.RGE ASSF1SSMENT1INST �CTIONS ; Loa 6 Nonnr6017101 ADM:W23rzoos <br /> To be completed by Nursing -•`: - DOB:001/1949 58Y SF.X,F (216)568-5e+t <br /> hb PAGE z Find:7o2578t <br /> 21M9-2961 'Addic i;sOlp h- <br /> Medication Dose Frequency <br /> , . <br /> *E= mucationa!sheets given and explained:•" P R Prescription given,not filled <br /> ge{er to attached of: Medicine Calendar MAR No Medications <br /> Ho italization• - <br /> Dint DvrinP sp Dietician Consult'Date•~ �l.Z�IO 5 ❑N/A <br /> Discharge Diet order: <br /> Order. <br /> Physician Activity rr.: .. . ... <br /> :..,.-hollow­up• <br /> [anithZd ucation•Summa. <br /> :��aderstand' Coiznnents;'•''~ Education Referral <br /> Diagnosis Xes ONo'�N/A <br /> Mcdication/Paiu Medication : : [�ides•,❑No�N/A t w Y <br /> potcnt0715Mg7Fbod7nteraction.': , 4 UN60N/�i'`' Y <br /> Potinciallhiig/Dnig�tx�ctton�- Yes,[�No.ON/1�► ., •: .'.� .,•• , ... • <br /> Nii�itioa• ' ''''• . . ':�Yes`[f No' /A x� . <br /> Oral Health []Yes❑No /A : . . .. <br /> Ac viry/Safety •❑Yes.QNo N/A <br /> Equipmeatl5ttpp]yUsc []Yea❑Na /A <br /> i Rehab Technignes ❑'Yes DNo. /A <br /> '..,J Set Caie/GioominS OX"ONo. . N/A ' <br /> Corunninity Resources es ONO;[IN/A <br /> Other. ❑Yes nNo QN/A <br /> instruction for Cans:��4' <br /> IV <br /> Af <br /> .�1rt�2����� Q� 2,lnl� . F�1�d4?/Gt.1� ° L Q•s—� <br /> �,/ 1,.i �„ �1,/ilit2 ••-Hd �iUS�i �P• , - �.��J•i•-�' A;t n'�i��, <br /> Physician appointment is: Card given: []Yes AN/A <br /> Patient will-make own appointment: ❑Yes )ZI.N/A <br /> Supplies/equipment given or has at.home: ON/A <br /> Patiend&mly has no fiuther questions-regarding discharge instructions at this time: ❑No (]Yes <br /> Comments: <br /> Valuables in Safe: gpo C]Yes Returned to pati t/farnily:❑Yes To whom: <br /> TimeMate of Reless : To Whom: <br /> Patient's Signature: Date: y _Z4 1. - <br /> Original to Chart/Photocopy to Pntien e e tng Faeil":[1 Yes Gi eb to:- <br /> RN Signature: LPN Signature: gf. ate: <br /> 10/04 <br />