AHCP Template for Manual Creation: English-Speaking Patients
This template is available for download in two formats:
PDF - 118.6 KB
Microsoft Word - 101.25 KB
** Bring this Plan to ALL Appointments**
After Hospital Care Plan for: [patient name]
[Patient name]
Discharge Date: [discharge date]
|
Question or Problem about this Packet? Call your Discharge Educator: (xxx) xxx-xxxx DE PHOTO HERE Serious health problem? Call Dr. __________________: (xxx) xxx-xxxx PCP PHOTO HERE |
EACH DAY follow this schedule:
MEDICINES
| What time of day do I take this medicine? |
Why am I taking this medicine? | Medicine name Amount |
How many do I take? | How do I take this medicine? |
|---|---|---|---|---|
 Morning |
||||
 Noon |
||||
 Evening |
||||
 Bedtime |
||||
| Only if you need it for | ||||
| Only if you need it for |
** Bring this Plan to ALL Appointments**
[Insert Patient Name]
What is my main medical problem?
[Insert Primary diagnosis]
When are my appointments?
| Date/time of appt | ||
|---|---|---|
| Provider name | ||
| Provider site information | ||
| Reason for appt | ||
| Provider phone number |
What exercises are good for me?
Default (if applicable):
[Walking is a very healthy form of exercise. Please do your best to walk for at least 20 minutes everyday.]
What should I eat?
Default (if applicable):
[Eating food that is low in fat and low in cholesterol will help you stay healthy.]
What are my medicine allergies?
REMEMBER you are allergic to [list medicine allergies].
Where is my pharmacy?
[Insert pharmacy name, location, contact information]
{If applicable, include:}
| TRY TO QUIT SMOKING: call [contact information] |
Questions / ConcernsFor my appointment with[PCP Name] |
|
Check the box and write notes to remember what to talk about with Dr. [PCP name] I have questions about: ___ My medicines ___________________________________________________________________________________ Dr. [PCP Name]: When I left the hospital, results from some tests were not available. Please check for results of these tests: [List tests done] ___ I am having trouble with the stairs in my house. |
