My Care Diary
Home Health / Hospice
RESOURCES
• I will be using:_____________________________________________________________________________________________
____________________________________________________________________________________________________________
• The agency will come to see me:____________________________________________________________________________
____________________________________________________________________________________________________________
• They will help with:_________________________________________________________________________________________
____________________________________________________________________________________________________________
• If I need to contact them, I should call:______________________________________________________________________
____________________________________________________________________________________________________________
Discharge Checklist
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 27