the patient’s checklist
TRANSCRIPT
![Page 1: The Patient’s Checklist](https://reader030.vdocuments.mx/reader030/viewer/2022012702/61a4a2118c1e937a8a3e8f58/html5/thumbnails/1.jpg)
The Patient’s ChecklistBy Elizabeth Bailey
Supplemental PDF
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THE PATIENT’S CHECKLIST—My Important Health Information
My Important Health InformationName: DOB: Insurance (name of carrier and member ID):
My Important ContactsContact 1: Phone: Relationship to me:
Contact 2: Phone: Relationship to me:
My Health- Care Proxy: Phone:
I have a health- care proxy: YES NO (see form attached)
I have a living will: YES NO (see form attached)
I use hearing aids , glasses , dentures , reading glasses .
My current health conditions (including any implants):
Current list of medications, allergies to medication, and over- the- counter meds that I take (name/dose/schedule):
My current doctors (name/number/why I see them):
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THE PATIENT’S CHECKLIST—Master Medication List
DRUG NAME DESCRIPTION DAILY SCHEDULE
TIME DOSAGE
DOCTOR WHY
SPECIAL INSTRUCTIONS
ADVERSE REACTIONS
DATE STARTED
DATE ENDED
DRUG NAME DESCRIPTION DAILY SCHEDULE
TIME DOSAGE
DOCTOR WHY
SPECIAL INSTRUCTIONS
ADVERSE REACTIONS
DATE STARTED
DATE ENDED
DRUG NAME DESCRIPTION DAILY SCHEDULE
TIME DOSAGE
DOCTOR WHY
SPECIAL INSTRUCTIONS
ADVERSE REACTIONS
DATE STARTED
DATE ENDED
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THE PATIENT’S CHECKLIST—Master Medication List
DRUG NAME DESCRIPTION DAILY SCHEDULE
TIME DOSAGE
DOCTOR WHY
SPECIAL INSTRUCTIONS
ADVERSE REACTIONS
DATE STARTED
DATE ENDED
DRUG NAME DESCRIPTION DAILY SCHEDULE
TIME DOSAGE
DOCTOR WHY
SPECIAL INSTRUCTIONS
ADVERSE REACTIONS
DATE STARTED
DATE ENDED
DRUG NAME DESCRIPTION DAILY SCHEDULE
TIME DOSAGE
DOCTOR WHY
SPECIAL INSTRUCTIONS
ADVERSE REACTIONS
DATE STARTED
DATE ENDED
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THE PATIENT’S CHECKLIST—Master Medication List
DRUG NAME DESCRIPTION DAILY SCHEDULE
TIME DOSAGE
DOCTOR WHY
SPECIAL INSTRUCTIONS
ADVERSE REACTIONS
DATE STARTED
DATE ENDED
DRUG NAME DESCRIPTION DAILY SCHEDULE
TIME DOSAGE
DOCTOR WHY
SPECIAL INSTRUCTIONS
ADVERSE REACTIONS
DATE STARTED
DATE ENDED
DRUG NAME DESCRIPTION DAILY SCHEDULE
TIME DOSAGE
DOCTOR WHY
SPECIAL INSTRUCTIONS
ADVERSE REACTIONS
DATE STARTED
DATE ENDED
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THE PATIENT’S CHECKLIST—Master Medication List
DRUG NAME DESCRIPTION DAILY SCHEDULE
TIME DOSAGE
DOCTOR WHY
SPECIAL INSTRUCTIONS
ADVERSE REACTIONS
DATE STARTED
DATE ENDED
DRUG NAME DESCRIPTION DAILY SCHEDULE
TIME DOSAGE
DOCTOR WHY
SPECIAL INSTRUCTIONS
ADVERSE REACTIONS
DATE STARTED
DATE ENDED
DRUG NAME DESCRIPTION DAILY SCHEDULE
TIME DOSAGE
DOCTOR WHY
SPECIAL INSTRUCTIONS
ADVERSE REACTIONS
DATE STARTED
DATE ENDED
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THE PATIENT’S CHECKLIST—Master Medication List
DRUG NAME DESCRIPTION DAILY SCHEDULE
TIME DOSAGE
DOCTOR WHY
SPECIAL INSTRUCTIONS
ADVERSE REACTIONS
DATE STARTED
DATE ENDED
DRUG NAME DESCRIPTION DAILY SCHEDULE
TIME DOSAGE
DOCTOR WHY
SPECIAL INSTRUCTIONS
ADVERSE REACTIONS
DATE STARTED
DATE ENDED
DRUG NAME DESCRIPTION DAILY SCHEDULE
TIME DOSAGE
DOCTOR WHY
SPECIAL INSTRUCTIONS
ADVERSE REACTIONS
DATE STARTED
DATE ENDED
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THE PATIENT’S CHECKLIST—Master Medication List
DRUG NAME DESCRIPTION DAILY SCHEDULE
TIME DOSAGE
DOCTOR WHY
SPECIAL INSTRUCTIONS
ADVERSE REACTIONS
DATE STARTED
DATE ENDED
DRUG NAME DESCRIPTION DAILY SCHEDULE
TIME DOSAGE
DOCTOR WHY
SPECIAL INSTRUCTIONS
ADVERSE REACTIONS
DATE STARTED
DATE ENDED
DRUG NAME DESCRIPTION DAILY SCHEDULE
TIME DOSAGE
DOCTOR WHY
SPECIAL INSTRUCTIONS
ADVERSE REACTIONS
DATE STARTED
DATE ENDED
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THE PATIENT’S CHECKLIST—Master Medication List
DRUG NAME DESCRIPTION DAILY SCHEDULE
TIME DOSAGE
DOCTOR WHY
SPECIAL INSTRUCTIONS
ADVERSE REACTIONS
DATE STARTED
DATE ENDED
DRUG NAME DESCRIPTION DAILY SCHEDULE
TIME DOSAGE
DOCTOR WHY
SPECIAL INSTRUCTIONS
ADVERSE REACTIONS
DATE STARTED
DATE ENDED
DRUG NAME DESCRIPTION DAILY SCHEDULE
TIME DOSAGE
DOCTOR WHY
SPECIAL INSTRUCTIONS
ADVERSE REACTIONS
DATE STARTED
DATE ENDED
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THE PATIENT’S CHECKLIST—Master Medication List
DRUG NAME DESCRIPTION DAILY SCHEDULE
TIME DOSAGE
DOCTOR WHY
SPECIAL INSTRUCTIONS
ADVERSE REACTIONS
DATE STARTED
DATE ENDED
DRUG NAME DESCRIPTION DAILY SCHEDULE
TIME DOSAGE
DOCTOR WHY
SPECIAL INSTRUCTIONS
ADVERSE REACTIONS
DATE STARTED
DATE ENDED
DRUG NAME DESCRIPTION DAILY SCHEDULE
TIME DOSAGE
DOCTOR WHY
SPECIAL INSTRUCTIONS
ADVERSE REACTIONS
DATE STARTED
DATE ENDED
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THE PATIENT’S CHECKLIST—Daily Medication Log
DATE: DAY:
TIME DRUG DOSAGE ROUTE ON TIME?
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
NOTES:
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THE PATIENT’S CHECKLIST—Daily Medication Log
DATE: DAY:
TIME DRUG DOSAGE ROUTE ON TIME?
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
NOTES:
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THE PATIENT’S CHECKLIST—Daily Medication Log
DATE: DAY:
TIME DRUG DOSAGE ROUTE ON TIME?
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
NOTES:
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THE PATIENT’S CHECKLIST—Daily Medication Log
DATE: DAY:
TIME DRUG DOSAGE ROUTE ON TIME?
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
NOTES:
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THE PATIENT’S CHECKLIST—Daily Medication Log
DATE: DAY:
TIME DRUG DOSAGE ROUTE ON TIME?
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
NOTES:
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THE PATIENT’S CHECKLIST—Daily Medication Log
DATE: DAY:
TIME DRUG DOSAGE ROUTE ON TIME?
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
NOTES:
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THE PATIENT’S CHECKLIST—Daily Medication Log
DATE: DAY:
TIME DRUG DOSAGE ROUTE ON TIME?
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
NOTES:
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THE PATIENT’S CHECKLIST—Daily Medication Log
DATE: DAY:
TIME DRUG DOSAGE ROUTE ON TIME?
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
NOTES:
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THE PATIENT’S CHECKLIST—Daily Medication Log
DATE: DAY:
TIME DRUG DOSAGE ROUTE ON TIME?
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
NOTES:
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THE PATIENT’S CHECKLIST—Daily Medication Log
DATE: DAY:
TIME DRUG DOSAGE ROUTE ON TIME?
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
ORAL IV SHOT OTHER
NOTES:
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THE PATIENT’S CHECKLIST—Daily Journal
DATE: DAY # OF HOSPITALIZATION: NURSES TODAY
Day Nurse: Shift Time:
Night Nurse: Shift Time:
Doctors seen today / Time:
Medications on time and correct?
Invasive devices (IV, catheter, ventilator, etc.) checked by nurse?
Is there a removal date?
What Happened Today? Refer to Daily Reminders Checklist.
RED FLAG
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THE PATIENT’S CHECKLIST—Daily Journal
DATE: DAY # OF HOSPITALIZATION: NURSES TODAY
Day Nurse: Shift Time:
Night Nurse: Shift Time:
Doctors seen today / Time:
Medications on time and correct?
Invasive devices (IV, catheter, ventilator, etc.) checked by nurse?
Is there a removal date?
What Happened Today? Refer to Daily Reminders Checklist.
RED FLAG
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THE PATIENT’S CHECKLIST—Daily Journal
DATE: DAY # OF HOSPITALIZATION: NURSES TODAY
Day Nurse: Shift Time:
Night Nurse: Shift Time:
Doctors seen today / Time:
Medications on time and correct?
Invasive devices (IV, catheter, ventilator, etc.) checked by nurse?
Is there a removal date?
What Happened Today? Refer to Daily Reminders Checklist.
RED FLAG
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THE PATIENT’S CHECKLIST—Daily Journal
DATE: DAY # OF HOSPITALIZATION: NURSES TODAY
Day Nurse: Shift Time:
Night Nurse: Shift Time:
Doctors seen today / Time:
Medications on time and correct?
Invasive devices (IV, catheter, ventilator, etc.) checked by nurse?
Is there a removal date?
What Happened Today? Refer to Daily Reminders Checklist.
RED FLAG
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THE PATIENT’S CHECKLIST—Daily Journal
DATE: DAY # OF HOSPITALIZATION: NURSES TODAY
Day Nurse: Shift Time:
Night Nurse: Shift Time:
Doctors seen today / Time:
Medications on time and correct?
Invasive devices (IV, catheter, ventilator, etc.) checked by nurse?
Is there a removal date?
What Happened Today? Refer to Daily Reminders Checklist.
RED FLAG
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THE PATIENT’S CHECKLIST—Daily Journal
DATE: DAY # OF HOSPITALIZATION: NURSES TODAY
Day Nurse: Shift Time:
Night Nurse: Shift Time:
Doctors seen today / Time:
Medications on time and correct?
Invasive devices (IV, catheter, ventilator, etc.) checked by nurse?
Is there a removal date?
What Happened Today? Refer to Daily Reminders Checklist.
RED FLAG
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THE PATIENT’S CHECKLIST—Daily Journal
DATE: DAY # OF HOSPITALIZATION: NURSES TODAY
Day Nurse: Shift Time:
Night Nurse: Shift Time:
Doctors seen today / Time:
Medications on time and correct?
Invasive devices (IV, catheter, ventilator, etc.) checked by nurse?
Is there a removal date?
What Happened Today? Refer to Daily Reminders Checklist.
RED FLAG
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THE PATIENT’S CHECKLIST—Daily Journal
DATE: DAY # OF HOSPITALIZATION: NURSES TODAY
Day Nurse: Shift Time:
Night Nurse: Shift Time:
Doctors seen today / Time:
Medications on time and correct?
Invasive devices (IV, catheter, ventilator, etc.) checked by nurse?
Is there a removal date?
What Happened Today? Refer to Daily Reminders Checklist.
RED FLAG
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THE PATIENT’S CHECKLIST—Daily Journal
DATE: DAY # OF HOSPITALIZATION: NURSES TODAY
Day Nurse: Shift Time:
Night Nurse: Shift Time:
Doctors seen today / Time:
Medications on time and correct?
Invasive devices (IV, catheter, ventilator, etc.) checked by nurse?
Is there a removal date?
What Happened Today? Refer to Daily Reminders Checklist.
RED FLAG
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THE PATIENT’S CHECKLIST—Daily Journal
DATE: DAY # OF HOSPITALIZATION: NURSES TODAY
Day Nurse: Shift Time:
Night Nurse: Shift Time:
Doctors seen today / Time:
Medications on time and correct?
Invasive devices (IV, catheter, ventilator, etc.) checked by nurse?
Is there a removal date?
What Happened Today? Refer to Daily Reminders Checklist.
RED FLAG
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THE PATIENT’S CHECKLIST—Daily Journal
DATE: DAY # OF HOSPITALIZATION: NURSES TODAY
Day Nurse: Shift Time:
Night Nurse: Shift Time:
Doctors seen today / Time:
Medications on time and correct?
Invasive devices (IV, catheter, ventilator, etc.) checked by nurse?
Is there a removal date?
What Happened Today? Refer to Daily Reminders Checklist.
RED FLAG
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THE PATIENT’S CHECKLIST—Daily Journal
DATE: DAY # OF HOSPITALIZATION: NURSES TODAY
Day Nurse: Shift Time:
Night Nurse: Shift Time:
Doctors seen today / Time:
Medications on time and correct?
Invasive devices (IV, catheter, ventilator, etc.) checked by nurse?
Is there a removal date?
What Happened Today? Refer to Daily Reminders Checklist.
RED FLAG
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THE PATIENT’S CHECKLIST—Daily Journal
DATE: DAY # OF HOSPITALIZATION: NURSES TODAY
Day Nurse: Shift Time:
Night Nurse: Shift Time:
Doctors seen today / Time:
Medications on time and correct?
Invasive devices (IV, catheter, ventilator, etc.) checked by nurse?
Is there a removal date?
What Happened Today? Refer to Daily Reminders Checklist.
RED FLAG
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THE PATIENT’S CHECKLIST—Insurance Information
Primary Insurance Provider (adapt from your card info)
Name of policyholder:
DOB and SS# of policyholder*:
Member ID#:
Group#:
Claims phone number:
Contact:
Secondary Insurance Provider (adapt from your card info)
Name of policyholder:
DOB and SS# of policyholder*:
Member ID#:
Group#:
Claims phone number:
Contact:
Prescription Drug ID Card (adapt from your card info)
ID#:
RxGrp:
RxBin:
Employer human resources contact (name/phone/email for contact):
Hospital billing dept. contact (name/phone/email for contact):
*If you are not the policyholder— spouse, parent, etc.
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THE PATIENT’S CHECKLIST—Hospital Information Page
HOSPITAL INFORMATION PAGE
Date of hospitalization:
MRN number:
Hospital name:
Address:
Main number:
Nurses’ station number for your floor:
Nurse manager name and number for your floor or unit:
Room number:
Room phone number:
Case manager:
Social worker:
Patient relations number (call if you have issues that are not being addressed):
Rehab facility if applicable:
Discharge instructions reviewed with:
Discharge services referrals (medical equipment, nursing services, PT, etc.):
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THE PATIENT’S CHECKLIST—Doctor Contacts
Doctor name:
Specialty:
Typical time for rounds:
Office phone: Cell phone:
Email:
Office receptionist:
Nurse practitioner: NP contact info:
Physician’s assistant: PA contact info:
Hospital resident/intern reporting to doctor:
Contact info:
Doctor name:
Specialty:
Typical time for rounds:
Office phone: Cell phone:
Email:
Office receptionist:
Nurse practitioner: NP contact info:
Physician’s assistant: PA contact info:
Hospital resident/intern reporting to doctor:
Contact info:
Special notes:
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THE PATIENT’S CHECKLIST—Doctor Contacts
Doctor name:
Specialty:
Typical time for rounds:
Office phone: Cell phone:
Email:
Office receptionist:
Nurse practitioner: NP contact info:
Physician’s assistant: PA contact info:
Hospital resident/intern reporting to doctor:
Contact info:
Doctor name:
Specialty:
Typical time for rounds:
Office phone: Cell phone:
Email:
Office receptionist:
Nurse practitioner: NP contact info:
Physician’s assistant: PA contact info:
Hospital resident/intern reporting to doctor:
Contact info:
Special notes:
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THE PATIENT’S CHECKLIST—Doctor Contacts
Doctor name:
Specialty:
Typical time for rounds:
Office phone: Cell phone:
Email:
Office receptionist:
Nurse practitioner: NP contact info:
Physician’s assistant: PA contact info:
Hospital resident/intern reporting to doctor:
Contact info:
Doctor name:
Specialty:
Typical time for rounds:
Office phone: Cell phone:
Email:
Office receptionist:
Nurse practitioner: NP contact info:
Physician’s assistant: PA contact info:
Hospital resident/intern reporting to doctor:
Contact info:
Special notes:
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THE PATIENT’S CHECKLIST—Doctor Contacts
Doctor name:
Specialty:
Typical time for rounds:
Office phone: Cell phone:
Email:
Office receptionist:
Nurse practitioner: NP contact info:
Physician’s assistant: PA contact info:
Hospital resident/intern reporting to doctor:
Contact info:
Doctor name:
Specialty:
Typical time for rounds:
Office phone: Cell phone:
Email:
Office receptionist:
Nurse practitioner: NP contact info:
Physician’s assistant: PA contact info:
Hospital resident/intern reporting to doctor:
Contact info:
Special notes:
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THE PATIENT’S CHECKLIST—Doctor Contacts
Doctor name:
Specialty:
Typical time for rounds:
Office phone: Cell phone:
Email:
Office receptionist:
Nurse practitioner: NP contact info:
Physician’s assistant: PA contact info:
Hospital resident/intern reporting to doctor:
Contact info:
Doctor name:
Specialty:
Typical time for rounds:
Office phone: Cell phone:
Email:
Office receptionist:
Nurse practitioner: NP contact info:
Physician’s assistant: PA contact info:
Hospital resident/intern reporting to doctor:
Contact info:
Special notes:
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THE PATIENT’S CHECKLIST—Doctor Contacts
Doctor name:
Specialty:
Typical time for rounds:
Office phone: Cell phone:
Email:
Office receptionist:
Nurse practitioner: NP contact info:
Physician’s assistant: PA contact info:
Hospital resident/intern reporting to doctor:
Contact info:
Doctor name:
Specialty:
Typical time for rounds:
Office phone: Cell phone:
Email:
Office receptionist:
Nurse practitioner: NP contact info:
Physician’s assistant: PA contact info:
Hospital resident/intern reporting to doctor:
Contact info:
Special notes:
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THE PATIENT’S CHECKLIST—Family & Friends Contacts
Name:
Cell: Landline:
Email:
Special notes:
Name:
Cell: Landline:
Email:
Special notes:
Name:
Cell: Landline:
Email:
Special notes:
Name:
Cell: Landline:
Email:
Special notes:
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THE PATIENT’S CHECKLIST—Family & Friends Contacts
Name:
Cell: Landline:
Email:
Special notes:
Name:
Cell: Landline:
Email:
Special notes:
Name:
Cell: Landline:
Email:
Special notes:
Name:
Cell: Landline:
Email:
Special notes:
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THE PATIENT’S CHECKLIST—Family & Friends Contacts
Name:
Cell: Landline:
Email:
Special notes:
Name:
Cell: Landline:
Email:
Special notes:
Name:
Cell: Landline:
Email:
Special notes:
Name:
Cell: Landline:
Email:
Special notes:
![Page 45: The Patient’s Checklist](https://reader030.vdocuments.mx/reader030/viewer/2022012702/61a4a2118c1e937a8a3e8f58/html5/thumbnails/45.jpg)
THE PATIENT’S CHECKLIST—Family & Friends Contacts
Name:
Cell: Landline:
Email:
Special notes:
Name:
Cell: Landline:
Email:
Special notes:
Name:
Cell: Landline:
Email:
Special notes:
Name:
Cell: Landline:
Email:
Special notes:
![Page 46: The Patient’s Checklist](https://reader030.vdocuments.mx/reader030/viewer/2022012702/61a4a2118c1e937a8a3e8f58/html5/thumbnails/46.jpg)
THE PATIENT’S CHECKLIST—Family & Friends Contacts
Name:
Cell: Landline:
Email:
Special notes:
Name:
Cell: Landline:
Email:
Special notes:
Name:
Cell: Landline:
Email:
Special notes:
Name:
Cell: Landline:
Email:
Special notes:
![Page 47: The Patient’s Checklist](https://reader030.vdocuments.mx/reader030/viewer/2022012702/61a4a2118c1e937a8a3e8f58/html5/thumbnails/47.jpg)
THE PATIENT’S CHECKLIST—Notes
Notes
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THE PATIENT’S CHECKLIST—Notes
Notes
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THE PATIENT’S CHECKLIST—Notes
Notes
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THE PATIENT’S CHECKLIST—Notes
Notes
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THE PATIENT’S CHECKLIST—Notes
Notes
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THE PATIENT’S CHECKLIST—Notes
Notes
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THE PATIENT’S CHECKLIST—Notes
Notes
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THE PATIENT’S CHECKLIST—Notes
Notes
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THE PATIENT’S CHECKLIST—Notes
Notes
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THE PATIENT’S CHECKLIST—Notes
Notes