Documentation Focus for Activity Intolerance

ASSESSMENT/REASSESSMENT
• Level of activity as noted in Functional Level Classification.
• Causative/precipitating factors.
• Client reports of difficulty/change.

PLANNING
• Plan of care and who is involved in planning.

IMPLEMENTATION/EVALUATION
• Response to interventions/teaching and actions performed.
• Implemented changes to plan of care based on assessment/reassessment findings.
• Teaching plan and response/understanding of teaching plan.
• Attainment/progress toward desired outcome(s).

DISCHARGE PLANNING
• Referrals to other resources.
• Long-term needs and who is responsible for actions.

source : Nurse’s Pocket Guide : Diagnoses, Prioritized Interventions, and Rationales
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