Attachment B -- Electronic template for the After Hospital Care Plan (example)

Attachment K. Electronic template for the After Hospital Care Plan (example)

After Hospital Care Plan Manual Entry Example, English speaking patients

** Bring this Plan to ALL Appointments**

After Hospital Care Plan for:

John Doe

D

Question or Problem about this Packet? Call your Discharge Advocate: (617) 444-1111

Serious health problem? Call Dr. Brian Jack: (617) 444-2222

ischarge Date: October 20, 2006

E ACH DAY follow this schedule:

MEDICINES

What time of day do I take this medicine?	Why am I taking this medicine?	Medication name Amount	How much do I take?	How do I take this medicine?
Morning Morning	Blood pressure	PROCARDIA XL NIFEDIPINE 90 mg	1 pill	By mouth
	Blood pressure	HYDROCHLOROTHIAZIDE 25 mg	1 pill	By mouth
	Blood pressure	CLONIDINE HCl 0.1 mg	3 pills	By mouth
	cholesterol	LIPITOR ATORVASTATIN CALCIUM 20 mg	1 pill	By mouth
	stomach	PROTONIX PANTOPRAZOLE SODIUM 40 mg	1 pill	By mouth
heart	ASPIRIN EC 325 mg	1 pill	By mouth
To stop smoking	NICOTINE 14 mg/24 hr	1 patch	On skin
Then, after 4 weeks use 	NICOTINE 7 mg/24 hr	1 patch	On skin
Blood pressure	COZAAR LOSARTAN POTASSIUM 50 mg	1 pill	By mouth
Infection in eye	VIGAMOX MOXIFLOXACIN HCl 0.5 % soln	1 drop	In your left eye
Noon	Blood pressure	ATENOLOL 75 mg	1 pill	By mouth
	Blood pressure	LISINOPRIL 40 m	1 pill	By mouth
Infection in eye	VIGAMOX MOXIFLOXACIN HCl 0.5 % soln	1 drop	In your left eye
Evening	Infection in eye	VIGAMOX MOXIFLOXACIN HCl 0.5 % soln	1 drop	In your left eye
Bedtime	Blood pressure	CLONIDINE HCl 0.1 mg	3 pills	By mouth
If you need it for headache	headache	TRAMADOL HCl 50 mg	1-2 pills Every 6 hours If you need it	By mouth
If you need it for chest pain	Chest pain	NITROGLYCERIN 0.4 mg	1 pill every 5 minutes (if need more than 3 pills, call 911)	Under your tongue
If you need it to stop smoking	To stop smoking	NICORELIEF NICOTINE POLACRILEX 4 mg gum	Gum	chew
If you need it for headaches	headache	PERCOCET OXYCODONE-ACETAMINOPHEN 5-325 mg	1 pill 3 times each day If you need it	By mouth

** Bring this Plan to ALL Appointments**

John Doe

Chest Pain

Tuesday, October 24th at 11:30 am	Thursday, October 26th at 3:20 pm	Wednesday November 1st at 9:00 am
Dr. Brian Jack Primary Care Physician (Doctor)	Dr. Jones Rheumatologist	Dr. Smith Cardiologist
at Boston Medical Center ACC – 2nd floor	at Boston Medical Center Doctor’s Office Building 4th floor	at Boston Medical Center Doctor’s Office Building 4th floor
For a Follow-up appointment	For your arthritis	to check your heart
Office Phone #: (617) 444-2222	Office Phone #: (617) 444-7777	Office Phone #: (617) 555-1234

Walk for at least 20 minutes each day.

Eating food that is low in fat and low in cholesterol will help you stay healthy.

REMEMBER you are ALLERGIC to MOTRIN.

CVS Pharmacy

1500 Lincoln Ave.

Boston, MA 02121

(617) 555-8888

TRY TO QUIT SMOKING: call Jane Jones at (617) 444-8888 at Boston Medical Center

Questions for

Dr. Jack

For my appointment on

Tuesday, October 24^th at 11:30 am

• I am having trouble with the stairs in my house.

• Someone I live with smokes.

• I feel stressed or overwhelmed.

• I am having trouble getting food.

• There are other things going on in my life that are effecting my health.

Check the box and write notes to remember what to talk about with Dr. Jack

I have questions about:

 my medicines _______________________________________

 my pain ____________________________________________

 feeling stressed ______________________________________

What other questions do you have? ________________________ _______________________________________________________________________________________________________________________________________________________________

• I am having trouble with the stairs in my house.

• Someone I live with smokes.

• I feel stressed or overwhelmed.

• I am having trouble getting food.

• There are other things going on in my life that are effecting my health.

• I am having trouble with the stairs in my house.

• Someone I live with smokes.

• I feel stressed or overwhelmed.

• I am having trouble getting food.

• There are other things going on in my life that are effecting my health.

• I am having trouble with the stairs in my house.

• Someone I live with smokes.

• I feel stressed or overwhelmed.

• I am having trouble getting food.

• There are other things going on in my life that are effecting my health.

• I am having trouble with the stairs in my house.

• Someone I live with smokes.

• I feel stressed or overwhelmed.

• I am having trouble getting food.

• There are other things going on in my life that are effecting my health.

Dr Jack:

When I left the hospital, results from some tests were not available. Please check for results of these tests.

• I am having trouble with the stairs in my house.

• Someone I live with smokes.

• I feel stressed or overwhelmed.

• I am having trouble getting food.

• There are other things going on in my life that are effecting my health.

October 2006

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
1	2	3	4	5	6	7
8	9	10	11	12	13	14
15	16	17	18	19	20 Left hospital	21
22	23 Pharmacist will call today or tomorrow	24 Dr. Jack at 11:30 am at Boston Medical Center ACC – 2nd floor	25	26 Dr. Jones at 3:20 pm at Boston Medical Center Doctor’s Office Building – 4th floor	27	28
29	30	31

November 2006

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
			1 Dr. Smith at 9:00 am at Boston Medical Center Doctor’s Office Building – 4th floor	2	3	4
5	6	7	8	9	10	11
12	13	14	15	16	17	18
19	20 Boston Medical Center will call about study	21	22	23	24	25
26	27	28	29	30

Noncardiac

Chest Pain

Noncardiac chest pain is chest pain that is not caused by a heart problem.

• If your chest pain gets different or worse, call your doctor.

• Take your medications as prescribed.

• Carry your medicine with you.

• See your doctor and ask questions.

Hypertension

Hypertension means high blood pressure.

• Try to walk for 20 minutes each day.

• Avoid salty foods.

• Take your medications as prescribed.

• Carry your medicine with you.

• See your doctor and ask questions.

After Hospital Care Plan Manual Entry Template, English speaking patients

** Bring this Plan to ALL Appointments**

After Hospital Care Plan for: [patient name]

Discharge Date: [discharge date]

Question or problem about this packet? Call your Discharge Advocate: (xxx) xxx-xxxx

Serious health problem or concern? Call Dr. [name]: (xxx) xxx-xxxx

EACH DAY follow this schedule:

MEDICINES

What time of day do I take this medicine?	Why am I taking this medicine?	Medication name Amount	How much do I take?	How do I take this medicine?
Morning 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]

[Insert Primary diagnosis]

Date/time of appt
Provider name
Provider site information
Reason for appt
Provider phone number

Default (if applicable):

[Walking is a very healthy form of exercise. Please do your best to walk for at least 20 minutes every day.]

Default (if applicable):

[Eating food that is low in fat and low in cholesterol will help you stay healthy.]

REMEMBER you are allergic to [list medication allergies].

[Insert pharmacy name, location, contact information]

{If applicable, include:}

TRY TO QUIT SMOKING: call [contact information]

Questions / Concerns

For my appointment with

[PCP Name]

• I am having trouble with the stairs in my house.

• Someone I live with smokes.

• I feel stressed or overwhelmed.

• I am having trouble getting food.

• There are other things going on in my life that are effecting my health.

Check the box and write notes to remember what to talk about with Dr. [PCP name]

I have questions about:

 my medicines __________________________________________

 my pain _______________________________________________

 feeling stressed _________________________________________

What other questions do you have? ___________________________ ________________________________________________________________________________________________________________________________________________________________________

• I am having trouble with the stairs in my house.

• Someone I live with smokes.

• I feel stressed or overwhelmed.

• I am having trouble getting food.

• There are other things going on in my life that are effecting my health.

• I am having trouble with the stairs in my house.

• Someone I live with smokes.

• I feel stressed or overwhelmed.

• I am having trouble getting food.

• There are other things going on in my life that are effecting my health.

• I am having trouble with the stairs in my house.

• Someone I live with smokes.

• I feel stressed or overwhelmed.

• I am having trouble getting food.

• There are other things going on in my life that are effecting my health.

• I am having trouble with the stairs in my house.

• Someone I live with smokes.

• I feel stressed or overwhelmed.

• I am having trouble getting food.

• There are other things going on in my life that are effecting my health.

Dr [PCP Name]:

When I left the hospital, results from some tests were not available. Please check for results of these tests:

• I am having trouble with the stairs in my house.

• Someone I live with smokes.

• I feel stressed or overwhelmed.

• I am having trouble getting food.

• There are other things going on in my life that are effecting my health.

[List tests done

After Hospital Care Plan Manual Entry Template, Non-English speaking patients (interpreter to write in translation below English text)

** Bring this Plan to ALL Appointments**

After Hospital Care Plan for: [patient name]

Discharge Date: [discharge date]

Question or problem about this booklet? Call your Discharge Advocate: (xxx) xxx-xxxx

Serious health problem or concern? Call Dr. [name ] : (xxx) xxx-xxxx

EACH DAY follow this schedule:

MEDICINES

What time of day do I take this medicine?	Why am I taking this medicine?	Medication name Amount	How much do I take?	How do I take this medicine?
Morning 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]

[Insert Primary diagnosis]

Date/time of appt
Provider name
Provider site information
Reason for appt
Provider phone number

Default (if applicable):

[Walking is a very healthy form of exercise. Please do your best to walk for at least 20 minutes every day.

Default (if applicable):

[Eating food that is low in fat and low in cholesterol will help you stay healthy.]

REMEMBER you are allergic to [list medication allergies].

[Insert pharmacy name, location, contact information]

{If applicable, include:}

TRY TO QUIT SMOKING: call [contact information]

• I am having trouble with the stairs in my house.

• Someone I live with smokes.

• I feel stressed or overwhelmed.

• I am having trouble getting food.

• There are other things going on in my life that are effecting my health.

Questions / Concerns

For 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 ____________________________________________________

 my pain _________________________________________________________

 feeling stressed ___________________________________________________

What other questions do you have? ________________________________________________________________________________________________________________________________________________________________________

• I am having trouble with the stairs in my house.

• Someone I live with smokes.

• I feel stressed or overwhelmed.

• I am having trouble getting food.

• There are other things going on in my life that are effecting my health.

• I am having trouble with the stairs in my house.

• Someone I live with smokes.

• I feel stressed or overwhelmed.

• I am having trouble getting food.

• There are other things going on in my life that are effecting my health.

Tests done in the hospital: Dr [PCP Name]:

When I left the hospital, results from some tests were not available. Please check for results of these tests:

• I am having trouble with the stairs in my house.

• Someone I live with smokes.

• I feel stressed or overwhelmed.

• I am having trouble getting food.

• There are other things going on in my life that are effecting my health.

[List tests done]