MY CARE DIARY
HOME HEALTH / HOSPICE
• I will be using :__________________________________________________________________________________
• The agency will come to see me :____________________________________________________________________
• They will help with :______________________________________________________________________________
• If I need to contact them , I should call :_______________________________________________________________
Check the box next to each item when you or your caregiver completes it .
n I know where I will receive care after discharge . n I have a care partner or support in place to help me ( name , phone number ). n I have someone to pick me up on the day of discharge ( name , phone number , pick-up location ). n I know the types of follow-up care I may need ( home health , physical therapy , occupational therapy , equipment ). n I know the special equipment or supplies I need and whom should be called to deliver them ( name , phone number ). n I have a list of options and community resources that I might need . n I have my medication list and I know how to take them . n I have my prescriptions or I know where and when to pick them up . n I have my follow-up appointments or know how and when to schedule them . n I know what I need to bring to my appointments . n I have a number to call to schedule or reschedule my appointments . n I understand all of my follow-up instructions .
n We have discussed if I am ready to do activities such as bathing , dressing , cooking , errands , bathroom , stairs , and doctor ’ s appointments .
n We have discussed if I will be able to get around my home without difficulty ( door widths , shower bars , bedroom locations , ramps , etc .).
n We have discussed the care that I must do at home ( trach care , tube feedings , other ). n I have been shown how to perform the care that I must do at home , and I am comfortable performing this care . n I know about signs or symptoms to look for after I leave . n I know whom to call in case of an emergency . uabmedicine . org 25