A7001-r13-24x36-OAF-f.ai 1 5/23/2014 11:13:19 AM / D Date: S M T / W T F Best Outcome for Every Patient Every Time S My Healthcare Team RN CM Nurse: MD Case Manager: Doctor: CNA Other: CALL... CNA: DON’T FALL! F Other: Please Retu rn Your Survey ! My Plan of Care T Today’s Tests & Treatments: My Goals Today: Special Instructions: Diet: Activity: A Other: NO PAIN 0 Discharge Plans: MILD PAIN 1 2 MODERATE PAIN 3 4 MODERATE PAIN 5 6 SEVERE PAIN 7 8 WORST PAIN POSSIBLE 9 10 / 10 Pain Goal Pain Med Last Given : AM Next Dose Available : AM PM PM Important Communications i il Questions: i Patient & Family What’s h iimportant ffor us to k know about b you as we care for you? 1. Contacts: Name * 2. Communica tion boar ds made p ossible by the Proct or Auxilia ry 3. * Use only non-abrasive cleaners. CaviWipes, Expo, isopropyl alcohol, soap & water and disinfectants OK with 6-year warranty from www.ahutton.com * Relationship Contact #
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