Driving Diagnosis Plans to be added to Care Plan
Driving Diagnosis is the diagnosis that has caused the majority of admissions as determined by the nurse provider
Clinical Goal
Address Driving Diagnosis:
Diabetes
Action Steps












Address Driving Diagnosis:
COPD / Asthma




Review signs/symptoms of hyper/hypo-glycemia
and associated treatment plans
Identify type of meter, lancets, strips
Provide log and Provide instruction around
proper BG logging
Request date of last HA1c
Teach the relationship between HA1c and long
term complications
Last eye Appointment Verified
Last foot Appointment Verified
Last dental Appointment Verified
Record name and most recent appointment of
endocrinologist as necessary
Connect with resources of local farmer’s markets
Provide diabetes education with reinforcement of
healthy plate
Refer to DSME class
Patient has O2 and nebulizer equipment in home
Teach behavior to improve breathing and
educate regarding precipitating factors of
exacerbations
Assess most recent PFT/Request from Provider
Completed pulmonary follow up post discharge
Date Due
Date
Complete
Days since
Enrollment
Clinical Goal
Address Driving Diagnosis:
Chronic Pain
Action Steps





Address Driving Diagnosis:
Hypertension










Compete pain assessment and continually
reassess
Assess triggers for pain onset
Identify underlying cause
Educate regarding complementary techniques
Follow up for pain management with specialist or
PCP
Coordinate receipt of an automated blood
pressure cuff
Instruction around and provide log for tracking
blood pressure and/or daily weight
Coordinate receipt of scale to assess weight
Instructed and reinforced on proper usage and
recording
Review signs/symptoms of
hyper/hypotension/causes and associated action
plans
Follow up for hypertension with PCP or specialty
Teach lifestyle behaviors to improve blood
pressure
Connect with local resources for complementary
therapies
Record most recent lipid panel/LFT
Record most recent PT/INR
Date Due
Date
Complete
Days since
Enrollment
Clinical Goal
Address Driving Diagnosis:
Heart Failure
Action Steps










Coordinate receipt of an automated blood
pressure cuff
Instruction around and provide log for tracking
blood pressure and/or daily weight
Coordinate receipt of scale to assess weight
Instructed and reinforced on proper usage and
recording
Review sign/symptoms/causes of heart failure
associated action plans
Follow up for hypertension with PCP or specialty
Teach lifestyle behaviors to improve blood
pressure
Connect with local resources for complementary
therapies
Record most recent lipid panel/LFT
Record most recent PT/INR
Date Due
Date
Complete
Days since
Enrollment
Clinical Goal
Address Driving Diagnosis:
Chest Pain / Disrhythmia
Action Steps










Address Driving Diagnosis:
ESRD





Coordinate receipt of an automated blood
pressure cuff
Instruction around and provide log for tracking
blood pressure and/or daily weight
Coordinate receipt of scale to assess weight
Instructed and reinforced on proper usage and
recording
Review signs/symptoms/causes of chest pain
and associated action plans
Follow up for hypertension with PCP or specialty
Teach lifestyle behaviors to improve blood
pressure
Connect with local resources for complementary
therapies
Record most recent lipid panel/LFT
Record most recent PT/INR
Teaching regarding fluid/electrolyte balance and
proper nutrition
Record most recent BUN/Creat.
Teach regarding complications of
hemo/peritoneal dialysis
Establish and record dialysis schedule, if
necessary
Specialty follow up to nephrology
Date Due
Date
Complete
Days since
Enrollment