A7001-r13-24x36-OAF-f.ai 1 5/23/2014 11:13:19 AM
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Date:
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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
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