help with my care plans

BahoRN · Oct 17, 2009

I assume you need help with your "As Evidenced By"?

Remember, your AEB is anything and everything you see, hear, smell...It can be something your patient says, lab work values, an order the Doctor has issued.

Example: Activity Intolerance r/t pneumonia AEB the patients states he has no energy, the patient starts sweating and shaking when performing ADLs, and the Doctor has ordered PT evaluations.

Hope that helps.

FLArn · Oct 17, 2009

mosby's used to have an index card style care planning guide arranged by nursing diagnosis. It's been a while since I've needed them -- lent mine to a CNA O worked with and she never returned them.

guest358111 · Oct 17, 2009

I didn't think that you could use a medical diagnosis as your r/t...would it look better to say "Impaired Liver Function r/t disease process secondary to Hepatitis C? Maybe it is fine the way it is, but I thought that the r/t can't be a medical diagnosis...

But maybe that was just the first part that couldn't be medical.... Just my input.

BahoRN · Oct 17, 2009

I didn't think that you could use a medical diagnosis as your r/t...would it look better to say "Impaired Liver Function r/t disease process secondary to Hepatitis C? Maybe it is fine the way it is, but I thought that the r/t can't be a medical diagnosis...
But maybe that was just the first part that couldn't be medical.... Just my input.

You are absolutely right! No medical diagnosis as your "related to".