Page 174 - Modul English Communication In Nursing

• Describe: ☐ Bathroom is within 3 meters
☐ Requires hallway access
☐ Requires wheelchair-accessible route

• Bathroom Type: ☐ Seated Toilet
☐ Squat Toilet
☐ Wheelchair-accessible Toilet
☐ Equipped with grab bars

Patient's Needs
• Basic needs ☐ Bathing support
requiring ☐ Dressing assistance
assistance: ☐ Meal preparation
☐ Mobility assistance
• Medical ☐ None
equipment to be ☐ Oxygen therapy
used at home after ☐ Blood pressure monitor
discharge: ☐ Blood sugar monitor
☐ Nebulizer
• Assistive devices ☐ None
needed after ☐ Walker
discharge: ☐ Cane
☐ Wheelchair
☐ Grab bars
• Special ☐ Assistance with meals
care/assistance ☐ Supervision for medication compliance
required at home ☐ General supervision from family member
after discharge: ☐ Physical therapy exercises
☐ Monitoring of vital signs

Acknowledgment:
”Bismillahirohmanirrohim, I solemnly declare that I have consciously and responsibly filled
out this form with accurate data.”

pg. 164