GEC REFERRAL CLC MEDICAL RECCOMENDATIONS DERIATRIC/TMP

CLC Referral Medical Recommendations
Rehabilitation
Medically complex requiring skilled nursing care:
Wound Care:
Location: 

Stage/description: 

Treatment: 

Response to treatment to date: 
Infection requiring IV antibiotics:

Site: 

Organism(s): 

Duration of IV treatment
start date: 
stop date: 

Monitoring parameters: 
Theraputic Interventions/Treatments
Radiation therapy


Provider of service documentation of plan and duration:


Purpose: 

Patient's awareness of purpose: 
Chemo therapy:
Treatment is 

Provider of service documentation of plan and duration:


Purpose: 

Patient's awareness of purpose: 
HBO: 
Treatment is 

Provider of service documentation of plan and duration:


Purpose: 

Patient's awareness of purpose: 
Restorative Care:
Function lost: 

Why: 

Goals: 

Interventions to attain goals: 

Response to date: 
Respite care: 
Pending placement: 
Other: 
Additional Indications

Other comments: