Policy Manual sample

MDT Home Health Care Agency, Inc. 186 PATIENT/FAMILY EDUCATION RECORD Patient Name: MR#: Learning Barriers Identified: Date Date Date  No Learning Barriers Identified  Impaired Vision  Impaired Hearing  Emotional/Psychological  Language Barrier  Impaired Thought Process  Reading Ability  Seems Disinterested in Learning  Not Receptive to Learning Date Information Taught Who Was Taught How Taught Patient/Family Understanding/Response Initials Comments Disease Process Instruction Sheet Safe and Effective Use of Medications Medication Instruction Sheet Nutrition Safe and Effective Use of Equipment Equipment Instruction Sheet Home Exercise Program Rehabilitation Techniques ADL Adaptation Personal Hygiene Healthy Living Discharge Instructions Initials Signature/Discipline Initials Signature/Discipline Initials Signature/Discipline Codes for Who Was Taught Codes for How Taught Patient/Family Understanding Pt = Patient D = Daughter A = Audio 1. Unable to verbalize basic concepts 6. Unable to perform return demonstrations S = Spouse Sn = Son V = Video 2. Verbalizes basic concepts with assistance 7. Demonstrates with cueing M = Mother C = Caretaker P = Printed 3. Verbalizes basic concepts without assistance 8. Demonstrates independently F = Father O = Other O = Oral 4. Verbally recalls instructions with assistance 9. Requires reinforcement/reinstruction D - Demonstrated 5. Verbally recalls instructions independently