Interdisciplinary Patient/ Family Education Record - Cont.

Admitting Diagnosis:CHF________________________________________________ Patients / Familys Preference for Learning (Please Check): Doing Reading TV Other:__________________________________________

Secondary Diagnosis:_____________________________________________________ Discussion Micromedex/Educational Materials Given: _________________________________________________ __________ ______________________ Date Signature _________________________________________________ __________ ______________________ Signature Date _________________________________________________ __________ ______________________
Date Signature

Date

Learner P=Patient F=Family O=Other

Learners Learners Learners Educational Barriers to Readiness Learning Needs Needs See Key III A: Assessed See Key II: Readiness See Key I: Y=Yes Educational Needs Barriers and Key III B: Level N=No

Method of Teaching Information Taught (Teaching Standard Used)

Learners Response Signature/Title Discipline

See Key IV: See Key V: Method Response

CHF Education: Activity level after discharge Diet/fluid intake after discharge Follow-up with Physician after discharge Medication instructions s/sof worsening CHF Daily weight monitoring CHF video # 162
INSTRUCTIONS:
1. In each key below, review and select appropriate codes [the number or letter(s) to the left of item(s)]

II. Barriers
1. 2. 3. 4. 5. 6. Age-Related Cognitive Cultural Emotional Hearing Financial 7. Language 8. Physical 9. Reading 10. Religious 11. Visual 12. None

IV. Method
(D) Demonstration (GR) Group Activity
(MED) Medication Instruction Sheet/Booklet

KEYS

2. In the boxes of the form above, enter the codes(s). NOTE: Boxes may require multiple code entries. EXAMPLE: For diabetic instructions about body changes, the codes selected from the I. Educational Needs Key may be: 1 (Body Functions), 4 (Disease Processes), 6 (Life Changes/Lifestyle Issues).

I. Educational Needs
To increase/enhance understanding of... 1. Body Functions 2. Community Resources 3. Discharge Instruction/Discharge Plan 4. Disease Processes 5. Follow-Up Instructions 6. Life Changes/Lifestyle Issues 7. Options for Care 8. Patient Rights/Responsibilities 9. Referral to Community Resources 10. Risks Associated with Care To increase skills with... 11. Activities of Daily Life 12. Diet/Nutrition 13. Equipment Use 14. Medication Use 15. Rehabilitation Techniques 16. Self Care 17. Health Behaviors/Prevention 18. Participation in Decisions About Own Care 19. Participation in Own Care To avoid/diminish... 20. Drug/Food Interactions 21. Injury /Accident 22. Negative Outcomes of Health Decisions Other... 23. No Need(s) Identified 24. Pre-Op Instructions 25. Other:__________________________ 26. Other:__________________________

III. A. Readiness
1. 2. 3. 4. 5. 6. Willing to Receive Instructions Understands Verbal Instructions Understands Written Instructions Understands Educational Needs All of the Above Not Ready (P) Poor (A) Average (E) Excellent

(P) Pamphlet (TV) Television/Video (V) Verbal Instructions (W) Written Instructions (O) Other (specifiy) _________________

V. Response
1. 2. 3. 4. 5. 6. 7. 8. Attentive/Interested/Responsive Inattentive/Disinterested/Unresponsive Questions Asked Verbal Recall/Understanding Skills Demonstration, with Assistance Skills Demonstration, without Assistance Needs Reinforcement Instructions Declined

III. B. Level (of Readiness)