Name: Congregation: Faith Community Nurse Network Month: Year: Of the Greater Twin Cities. Monthly Summary
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1 Name: Congregation: Faith Community Nurse Network Month: Year: Of the Greater Twin Cities Monthly Summary I. CLIENT INTERACTIONS A. New Follow-up B. Male Female C. Member Non-Member D. Location Total # of Interactions C O H HV NH P PA E Other (CODE: C = CONGREGATION; O = OFFICE; H = HOSPITAL; HV = HOME VISIT; NH = NURSING HOME; P = PHONE; PA = PANTRY; E = ) E. Age over 80 unknown F. Ethnic Heritage Caucasian African American/Black Hispanic Asian/Oriental Native American Middle Eastern Far Eastern Multi-cultural Unknown Other II. III. PURPOSE OF INTERACTION A. Spiritual C. Psychosocial Advanced Care Planning B. Health/Wellness Issue D. Safety/Environment Cancer E. Financial Cardiovascular Chronic disease F. Other GI (specify) GU/Reproductive Infectious disease Mental health Musculoskeletal Pulmonary Sensory Health-seeking behavior Other (specify) INTERVENTIONS A. Spiritual Care C. Supportive Care B. Health Teaching D. Assessment Permission granted for use without changes by Advocate Parish Nurse Ministry
2 IV. REFERRALS Referral From: S M NM CS MD HCP ME PN FAM Other Total AHC Referrals (CODE: S = SELF; M = MEMBER; NM = NON-MEMBER; CS = CONGREGATIONAL STAFF; MD = PHYSICIAN; HCP = HEALTH CARE PROFESSIONAL; ME = MEDIA; PN = PARISH NURSE; FAM = FAMILY) Referral To: CS CR HCP COM MD PN EdR Other Total AHC Referrals (CODE: CS = CONGREGATIONAL STAFF; CR = CONGREGATIONAL RESOURCE; HCP = HEALTH CARE PROFESSIONAL; COM = COMMUNITY; MD = PHYSICIAN; PN = PARISH NURSE; EdR = EDUCATIONAL RESOURCES) V. CONGREGATIONAL PARTNERSHIPS (Please use back page for additional space-include section #) A. Meetings # of mtgs.: Hrs: B. Congregational Activities # attended: Hrs: Clergy/Staff Worship Services Congregational Comm. Funerals/Wakes Community Comm. Social Events/Fellowship Other Other VI. GROUP CONTACTS Date Category Title # parti Age Target Prep Program PN Comments cipants Range Audience Time Time Code (Screening= PAB/ or AB) (CATEGORY CODE: EP = EDUCATIONAL PROGRAM; SG = SUPPORT GROUP; VM = VOLUNTEER MINISTRY; CP = COMMUNITY PARTNERSHIP; SCR = SCREENING; HF = HEALTH FAIR; SD = SPIRITUAL DEVELOPMENT; ESD = EDUCATIONAL AND SPIRITUAL DEVELOPMENT; O = OTHER) (PN CODE: CD = COORDINATOR/DEVELOPER; FA = FACILITATOR; P = PRESENTOR; PA = PARTICIPANT; O = OTHER) Permission granted for use without changes by Advocate Parish Nurse Ministry
3 VII. COMMUNICATION Category Topic Comments (CATEGORY CODE: CC = CONGREGATIONAL COMMUNICATION; CN = COMMUNITY NETWORKING; HD = HEALTH DISPLAY; R = REPORT; O = OTHER) VIII. PARISH NURSE PROFESSIONAL ACTIVITIES Category Title Comments (CATEGORY CODE: PN = PN MEETINGS; R = RETREAT; CE = CONTINUING EDUCATION [WORKSHOPS, INSERVICES]; CW = COURSE WORK; PL = PROFESSIONAL LITERATURE; SD = SPIRITUAL DEVELOPMENT; P/M = PRECEPTING/MENTORING; L = LIAISON; GS = GUEST SPEAKER/LECTURER; A = AUTHORSHIP of ARTICLES; O = OTHER) IX. RESOURCES USED (This section captures 1:1, group and general resources used) Resources Used: CS CR EdR HCP COM FAM PN OTHER Total AHC Resources (CODE: CS=CONGREGATIONAL STAFF; CR=CONGREGATIONAL RESOURCE; EdR=EDUCATIONAL RESOURCE; HCP=HEALTH CARE PROFESSIONAL; COM=COMMUNITY; FAM=FAMILY; PN=PARISH NURSE Permission granted for use without changes by Advocate Parish Nurse Ministry
4 X. TIME MANAGEMENT SUMMARY Paid Unpaid Total (Includes PTO) Please approximate the amount of hours spent on: Direct Client Interactions Indirect Client Activities Direct Group Contact Indirect Group Activities Congregational Partnerships Documentation Communication Parish Nurse Professional Activities XI. PRIMARY FOCUS OF PARISH NURSE MINISTRY/NARRATIVE SPECIFIC TO NAVIGATION OF CLIENTS INTO THE ADVOCATE This form has been developed by Advocate Health Care Parish Nurse Ministry 2009 Permission granted for use without changes by Advocate Parish Nurse Ministry
5 Permission granted for use without changes by Advocate Parish Nurse Ministry
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