Community Parish Nurse Program Monthly Statistics


Name(s) (please separate the names with a comma)  

Month/Year    

Church/Area    

 

Monthly Number of Individual Contacts

A. Initial             Follow-up             Total

B. Male             Female

C. Age:

0-12             13-17             18-30

31-50             51-65             66-80

Over 80

 

Health Concerns (place number next to concerns)

Preventative             Acute            Chronic

Behavioral             Family          New Baby

Safety & Environment             Spirituality

Bereavement         Counseling         Education

Arrangements         Advocacy

Guidance through Health Care System (specify)

Other

 

Setting (place numbers)

(code: C=Church, HV=Home Visit, H=Hospital, NH=Nursing Home, PC=Phone Call)

C           HV            H

NH           PC            Card Ministry

Other

Referral (place numbers)

(code: PS=Pastoral Staff, CH=Church Resources, HCP=Other Health Care Professional, MD=Physician, COM=Community Resources)

PS            CH            HCP

MD             COM             Other

 

Total time worked this month by parish nurse(s)     

Meet with Pastor    

Health & Wellness Committee Meeting

 

Screening

Type

#Screened

#Abnormal

#Referred

 

Program and Activities Organized/Attended by Parish Nurse (Bulletin, Health Display, etc.) (please separate with a comma)  

 

COMPLETED FORM DUE TO COORDINATOR BY THE 5TH OF EACH MONTH

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