What your CHW might do:
- Review health history and PCP care plan prior to visit.
- Answer any questions and address any concerns you have.
- Review any discharge instructions from any hospital, emergency room, and/or doctor visits.
- Review goals from previous visit:__________
- Assess adherence to care plan, including diet, exercise, medications, and keeping appointments.
- Review disease process and prevention measures with you including how and when to correctly take your medications.
- Education on kidney disease is to be expected for every encounter specific to your diagnosis(es).
- Education on healthy eating and living habits is to be expected for every encounter.
- Specific education on medications as they relates to kidney disease will be provided.
- Review of recent dialysis appointments, transportation to dialysis, and urinary output.
- Assessment of your shunt or port location.
- Complete a History and Physical Exam.
- A complete Medications Reconciliation is to be expected at every encounter.
- Complete a Safety Assessment.
- Complete a Social Assessment.
- Facilitate a Telehealth visit, if scheduled.
- Follow any verbal orders as obtained via telehealth, phone call, or electronic messaging.
- Schedule follow-up appointment(s) as needed that might include, but not limited to: Primary Care Provider, Addiction Recovery, Behavioral Health, Dental Care, Dietician, Home Health, Home Medical Equipment, Hospice, Pharmacy Services, Therapy Services, Public Health, Wound Care
- Establish goals for next visit:__________
What your CP might do:
- Ensure completion of applicable CHW items above.
- Perform venous blood draw for the following test panel:
- BMP
- GFR
- Magnesium
- Phosphorus
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