Congregation Name: Month(s)/Year: Number of congregation members:
Parish Nurse Name: #of hours worked: Paid: unpaid: #of unpaid miles:
Blood Pressure Screenings: Number of BP checks done: Number of referrals for abnormal BP:
Number of: Bulletin board displays: Newsletter/Bulletin Articles: Presentations:
Number of sessions lead: Living Well with Chronic Conditions: Matter of Balance/Stepping On: Other: Please indicate what other sessions you have lead:
Number of Visits (Please indicate 'NP' if non parishioner): At Chruch (don't count BP contacts): Home: Nursing Home/Assisted Living: Hospital: Telephone Contacts: Care Transitions Coach Contacts:
Number of Referrals made to: Pastor: MD/other health professional: Community agency: Other:
Number of Interventions Health teaching/counseling: Crisis Intervention: Bereavement: Rites/Rituals: Support: Community liaison/Referral: Correspondence: Assessment:
Other PN Activities (indicate the number of times you participate in the activity per month) Facilitate/participate in groups: List where you have participated in groups: Misc: List all miscellaneous activities you have participated in:
Outcomes and Improvements resulting from visits and other PN activities (indicate number of times) Enhanced quality of life: Enhanced independent living (includes medical device obtained): Disease risk reduction: Injury prevention: Hospital/ER avoidance: Appropriate referral to hospital/ER referral: Specefic comments to clarify outcomes/parishioners remarks:
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