Intervention Report

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CHURCH OF GOD IN CHRIST, INC.

INTERNATIONAL NURSES’ UNIT

Nurses’ Unit Intervention Form

 

Date: ______________                                                                                                    Time: _________________

 

Name: _______________________________________________________     Age_________      M ____ F ____

 

Address: _________________________________________________________  Phone: ___________________

 

Local Address/Room/Phone #: _________________________________________________________________ 

 

Complaint: _________________________________________________________________________________

 

___________________________________________________________________________________________

 

Assessment/Intervention: ______________________________________________________________________

 

___________________________________________________________________________________________

 

B/P ______/______    Pulse _________    Respirations _________    Blood Sugar _________   Other _________

 

Disposition/Recommendations/Counseling/Follow-up:_______________________________________________

 

___________________________________________________________________________________________

 

Form completed by: __________________________________________________________________________

 

 

 

 

 

 

 

 

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