Re-Engineered Discharge (RED) Toolkit

Tool 3 Continued

AHCP Template for Manual Creation: English-Speaking Patients

This template is available for download in two formats:


** 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?
Image of the sun.
Morning
       
       
       
       
       
       
       
       
       
Image of a clock with both hands pointing directly up.
Noon
       
       
       
Image of a crescent moon.
Evening
       
       
Image of a bed.
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 / 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? ___________________________________________________________________________________________

_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________
 

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.
___ 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 affecting my health.

Page last reviewed March 2013
Internet Citation: Tool 3 Continued. March 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/red/toolkit/ahcp-template-eng.html