Primary Care Nurse Template for Established Patients
A comprehensive primary care nurse template for established patients should include patient assessment, care planning, implementation, and follow-up components that focus on improving patient outcomes through systematic documentation and care delivery.
Patient Assessment Components
Vital Signs and Basic Assessment
- Complete set of vital signs including temperature, pulse, blood pressure, respiratory rate, oxygen saturation, pain level, level of consciousness, and urine output when applicable 1
- Height, weight, and BMI calculation 2
- Medication reconciliation (current medications, dosages, adherence) 2
- Allergies and adverse reactions 2
Health Status Documentation
- Chief complaint and reason for visit 3
- History of present illness (HPI) - identified as one of the most important sections by physicians 3
- Review of relevant body systems - though physicians may consider extensive ROS superfluous, focused relevant systems should be included 3
- Assessment of functional impairment in different domains (home, work, school) 2
Risk Assessment and Screening
- Cardiovascular risk factors assessment 2
- Depression screening for appropriate patients 2
- Fall risk assessment 2
- Immunization status review 2
- Substance use assessment (alcohol, tobacco, other substances) 2
Care Planning Components
Collaborative Goal Setting
- Documentation of patient-identified problems and priorities 2
- Establishment of specific, measurable goals in key areas of functioning (home, work, school) 2
- Development of action plans based on achievable patient goals 2
- Safety planning when applicable (especially for patients with depression or other risk factors) 2
Treatment Planning
- Documentation of treatment plan that prioritizes goals and outlines intervention strategies 2
- Medication management plan 2
- Lifestyle modification recommendations (diet, exercise, stress management) 2
- Patient education needs and plan 2
Implementation Components
Patient Education and Self-Management Support
- Documentation of education provided regarding:
Care Coordination
- Referrals to specialists or allied health professionals 2
- Referrals to community resources for social determinants of health 2
- Communication with other healthcare team members 2
- Documentation of care team roles and responsibilities 4
Disease-Specific Management
- Chronic disease management documentation (diabetes, hypertension, heart failure, etc.) 2
- Adherence to clinical practice guidelines for specific conditions 2
- Use of standardized templates or protocols for common conditions 2
Follow-Up Components
Return Visit Planning
- Documentation of follow-up plan with specific timeframe 2
- Identification of issues requiring monitoring before next visit 2
- Plan for interim communication if needed 2
Quality Improvement
- Documentation of progress toward treatment goals 2
- Identification of barriers to care 2
- Quality metrics tracking relevant to patient conditions 2
Documentation Best Practices
Electronic Health Record Optimization
- Use of structured templates to ensure comprehensive documentation 2
- Prioritization of most relevant information (HPI, Assessment and Plan) at top or in easily accessible format 3
- Integration of decision support tools when available 2
- Balance between structured data entry and narrative information 2
Patient-Centered Communication
- Documentation of patient's understanding of plan 2
- Documentation of shared decision-making process 2
- Use of patient-friendly language in education materials 2
- Consideration of cultural factors affecting care 2
Implementation Considerations
Workflow Integration
- Template should support rather than hinder nurse-patient interaction 2
- Design should minimize documentation burden while capturing essential information 2
- Format should facilitate communication between team members 4
- Template should be adaptable to different visit types while maintaining core elements 5