ICF Medical Plan of Care Notification
Individual Name (receiving services)
First Name
Last Name
Medical Care Plan Implemented for: (at risk for hospitalizations due to the following conditions)
Cardiac
Gastroenterology/ or Colostomy
Respiratory/lung
Endocrinology-diabetes
Psychiatric
Seizures/tremors
Bone and Joint Health and or low vit D
Eye Issues
Dementia
Hearing impairment/Deaf
Urology/ prostrate
Constipation
Skin irregularities
Thyroid conditions
Neoplastic Disease
Missed more than a total of 2 weeks of scheduled day activities or employment due to medical conditions during the past year
Allergies or intolerance
Paralysis
Dental/oral
Stroke TIA
Potential altered body temp/ temp risk
Female gynecologic
Neurological- SIADH, Cerebral Palsy
Hospice **refer to hoapice provider care plan
Kidney
Noncompliance w medical trmt
Cognitive developmental Downs Fragile X autism
Weight issues overweight
Weight issues underweight
Sleep disorder
Dysphagia NPO or tube feeding
Blood disorder
Other
ICF LOCATION:
Park West
Johnstown
Date of Care Plan update:
-
Month
-
Day
Year
Date
Further details or explanation of above:
QIDP email (assigned to individual)
example@example.com
Nurse implementing care plan:
First Name
Last Name
Submit
Should be Empty: