* = Required Information
Pt/Family overwhelmed
Needs community referrals
Unable to buy meds
End of life issues
Needs assistance developing Advance Directive/DNR
Crisis Interventions
Housing issues
No support system
Possible abuse/neglect issues
Long term planning
Depression
End of life issues
Anxious
Suicidal thoughts
Dangerous to others
Abusive to family/staff
Non-compliant w/ medical care
Altered mentation
Illness denial
Lack of coping skills
Decreased mobility
Fracture/Joint replacement
Needs assistive devices
Safety evaluation
Limitation in ROM
Decreased muscle strength
Impaired balance with risk
Unable to bathe self
Unable to feed self
Unable to dress self
Unable to toilet self
Safety Evaluation
Hand & upper extremity weakness
ADL training
Depression affecting ADL
Tub transfer equipment
Adaptive equipment
Needs temporary assist with ADL
Pressure Sores
Swallowing problems
Cognitive & memory problems
Trach patients
Non-healing wounds
New/uncontrolled DM
Significant WT change
Tube feedings
TPN patients
Therapeutic diet education
Inability to obtain meals
Disease related anorexia

Glossary of Medical Terms:
ADL = Activities of Daily Living
DNR = Do Not Resuscitate
Pt = Patient
ROM= Range Of Motion
TPN = Total Parenteral Nutrition; Intra-venous Feeding
WT= Weight