Skilled Nursing	Speech Therapy
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Physical Therapy	Medical Social Services
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Occupational Therepy	Home Health Aide
Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9	Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9

DME
checked>4 Wheeled walker	checked>long leg brace
checked>AFL	checked>nebulizer
checked>bath bench	checked>ostomy supplies
checked>cane	checked>oxygen supplies
checked>commode	checked>reacher
checked>diabetic supplies	checked>rolling walker
checked>eggcrate	checked>sliding board
checked>enema supplies	checked>sling
checked>feeding pump	checked>small base cane
checked>feeding tube supplies	checked>sock aid
checked>grab bars	checked>TENs unit
checked>hand held shower	checked>urinary/catheter supplies
checked>hospital bed	checked>ventilator and supplies
checked>hoyer lift	checked>walker
checked>IV supplies	checked>wheelchair
checked>L H. shoe horn	checked>wound care supplies
checked>L H. sponge	checked>Other...
large base quad cane

Safety Measures
checked>activity supervision		checked>no bp right arm
checked>ambulates with assistance		checked>no constrictive clothing
checked>ambulates with devices		checked>no lifting
checked>anticoagulant precautions		checked>no reaching
checked>aspiration precautions		checked>no steir use
checked>avoid temperature extremes		checked>no straining
checked>bathroom safety		checked>non-slip surface in tub
checked>bedrails up while in bed		checked>non-weight bearing LLE
checked>bleeding precautions		checked>non-weight bearing RLE
checked>cardiac precautions		checked>O2 Precautions
checked>child-safe anvironment		checked>posey while OOB
checked>diabetic precautions		checked>remove environmental barriers
checked>electrical safety measures		checked>restricted ROM
checked>emergency phone number prominently displayed		checked>seizure precautions
checked>fall precautions		checked>sharps precautions
checked>hand rails		checked>smoke detectors
checked>hip precautions		checked>standard precautions
checked>inadequate med/food prep area		checked>supervision at all times
checked>inadequate medication storage area		checked>toe-touch weight bearing LLE
checked>infectious material management		checked>toe-touch weight bearing RLE
checked>knee precautions		checked>transfer with assist
checked>medical bootbox.alert/lifeline		checked>walker precautions
checked>medical saftey		checked>wheelchair percautions
checked>no bending		checked>Other...
checked>no bp left arm

Nutrition
1000cal ADA	high calorie
1200cal ADA	high fiber
1400cal ADA	high protein
1500cal ADA	low cholesterol
1800cal ADA	low fiber
2gm sodium	low sodium
4gm sodium	NG feeding
bland	pureed
cardiac diet	regular
diabetic	renal diet
fluid restriction	soft
fluid for hydration	TPN
full-liquid	vegetarian diet
gastrostomy	Other...
G-Tube

Discharge Plan
care of family
day care program
discharge not planned
homemaker
indefinite care
nursing home placement
Patient/family paying for care indefinitely
private duty caregiver
self-care
self-care with emergency-response system
self-care with meals-on-wheels
skilled outpatient services
terminal condition-discharge not planned
Others...