Your Personal Plan

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Please use for reference only.

Penn Home Infusion Team
University of Pennsylvania Health System
Last Modified: November 1, 2001

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Type of Home Infusion Therapy _____________________________________________
Visiting Nurse Agency _____________________________________________
Doctor _____________________________________________
Nurse _____________________________________________
Pharmacist _____________________________________________
Dietitian _____________________________________________
Infusion Regimen _____________________________________________


Times Per Day _______________

Start Time(s) _______________

Finish Time(s) _______________

Rate _______________
Number of Days Per Week _______________
Change Dressings _______________

Weight _______________

Temperature _______________

Blood Sugar _______________


Additional Instructions ______________________________________________

______________________________________________

______________________________________________



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