Healthcare Treatment Chart Page 2

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Med 4
HEALTHCARE TREATMENT CHART
Name of the person
Month (or months) and year
Name:
Month(s)/Year:
Frequency of treatment
Name of ordering Healthcare Professional
Schedule:
Ordered By:
Directions for healthcare treatment or
Healthcare
Instructions
Title of healthcare treatment
information on where to find instructions
Treatment:
for Staff:
(such as “see PT exercises sheet”; “see RN 4”
Mo.
Time
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Staff will initial the specific date after providing the treatment
Date/Time:
Developed By:
Reviewed By:
Date/Time:
Initials of staff developing the chart along with date & time
Initials of staff reviewing the chart along with date & time
Initials
Signature
Position
Signature
Position
Initials
Signature of staff documenting on form along with position and initials
11/13
Med 4 Chart, Page 2 of 2

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