Comprehensive Primary Care Nurse Template for Established Patients

Patient Assessment Components

• The American Academy of Pediatrics recommends assessment of functional impairment in different domains (home, work, school) 3
• The American Heart Association suggests cardiovascular risk factors assessment, including review of immunization status and substance use assessment (alcohol, tobacco, other substances) 4, 2
• The American Heart Association recommends medication reconciliation (current medications, dosages, adherence) and review of allergies and adverse reactions 2
• Height, weight, and BMI calculation are essential components of patient assessment, as recommended by the American Society for Nutrition 1

Care Planning Components

• The American Academy of Pediatrics recommends establishment of specific, measurable goals in key areas of functioning (home, work, school) and development of action plans based on achievable patient goals 3, 5
• The American Heart Association suggests documentation of treatment plan that prioritizes goals and outlines intervention strategies, including medication management plan and lifestyle modification recommendations (diet, exercise, stress management) 2, 4

Implementation Components

• The American Heart Association recommends patient education on medication instructions, recognition of worsening symptoms, diet counseling relevant to condition, and activity counseling and restrictions 4, 2
• The American Stroke Association suggests self-monitoring instructions (weight, blood pressure, blood glucose as applicable) and referrals to specialists or allied health professionals 5, 4

Follow-Up Components

• The American Heart Association recommends documentation of follow-up plan with specific timeframe and identification of issues requiring monitoring before next visit 4, 5
• The American Medical Informatics Association suggests quality metrics tracking relevant to patient conditions 7

Documentation Best Practices

• The International Journal of Nursing Studies recommends use of structured templates to ensure comprehensive documentation and integration of decision support tools when available 6, 7
• The Journal of the American Medical Informatics Association suggests balance between structured data entry and narrative information and use of patient-friendly language in education materials 8, 6

Implementation Considerations

• The Journal of the American Medical Informatics Association recommends template design that minimizes documentation burden while capturing essential information and regular updates based on changing guidelines and evidence 7, 6
• The International Journal of Nursing Studies suggests nurses should receive training on proper use of the template and feedback mechanism for template improvement 6, 7