pfe

Kingdom of Saudi Arabia Ministry of Health Directorate of Health Affairs - Najran NAJRAN GENERAL HOSPITAL

INTERDISCIPLINARY PATIENT/ FAMILY EDUCATION FORM NAME: _____________________________ _________________________________________ _____________________________ ________________________ _______ FILE #: _____________________________  _____________________________  NATIONALITY: ___________________ ________________________ _____ AGE: __________ __________ SEX: __________________ __________________ DEPARTMENT: _________________  _________________  Reason for Admission: ______________________ __________________________________ _________________________ _________________________ _________________________ _________________________ _________________  _____  Section I. Detailed Patient Assessment to be Accomplised by Patient Educators/ Nurse within 48 hours of admission Patient’s Initial Learning Assessment Learner  Patient Spouse Father  Mother  Watcher  Reading Ability Barriers to Learning Communication Knowledge of  Motivation/ Family Assistance Language Disease is Readiness to Provided: Able to read None learn Arabic Good Often Able to count Cognitive Motivated Other  Limited Sometime Has difficulty Sensory impairment  _____________   _____________  Not Motivated None Needed Does not read Cultural  _____________   ______ _______  Ready to learn Comments Does not apply Comments Religious belief   _____________   ______ _______   _____________   ______ _______  Delay teaching  _____________  ________________  ___  Comments Language  _____________   _____________   _____________   _____________  Comment  _____________  ________________  ___  Comments  ______________  _______________  _   _____________   ______ _______   _____________   ______ _______   _____________  ______ _________  __   ______________  ______ _________  _   ____________  ___________________ __________  ___ 

Are there any cultural/ religious practice that may affect the patient healthcare?  Yes No Comments  _____________  _______________  __ 

Name: ______________________________________________________ Code# ________________ Signature __________________ Date ______________  Section II. General Information Provided (to be completed by Patient Educator/ Nurse) Received information about falls safety  Yes No Received written information about medical condition (e.g. leaflet)  Yes No Not Available Other ____________________________________________________________________________________________________________________________  Name: ______________________________________________________ Code# ________________ Signature __________________ Date ______________  Section III. Patient Relation (to completed by Patient Relation Officer) Received booklet on patient’s rights and responsibilities  Yes No Received information in watcher’s rules and regulations  Yes No Not Available Other ____________________________________________________________________________________________________________________________  Date Time Notes Code Number Signature

Note: Please refer to assessment by Patient Educators (Section I) Section IV. Detailed Patient Education Patient’s Education Provided: 1. CONDITION (Physicians) Referred to Patient Education on _______________ 

Diagnosis Date Time

 Yes

No

Procedure  Yes No Teaching Provided

Referred to plan of care

Self-Management

Other ____________________ 

 Yes No Treatment Plan Code Number Signature

 Yes No Patient’s Response

Patient’s Response to Teaching Session:

1. Able to perform/ verbalize 2. Unable to perform/ verbalize 3. Needs reinforcement 4. Not receptive (Nurses 2. PRE-/POST-OPERATIVE CARE ) N/A Ambulation Dressing Changes Other ______________________________  Date Time Teaching Provided Code Number Signature Patient’s Response

Patient’s Response to Teaching Session:

1. Able to perform/ verbalize 2. Unable to perform/ verbalize 3. Needs reinforcement 4. Not receptive 3. MEDICATION (Nurses/ Pharmacists) Purpose Side Effects Dosage Other ______________________________  Referred to Pharmacist/ Clinical Pharmacist on ________________________________________  Date Time Teaching Provided Code Number Signature Patient’s Response

Patient’s Response to Teaching Session:

4.

1. Able to perform/ verbalize NUTRITION (Nurses/ Dietitian) Date

Time

2. Unable to perform/ verbalize 3. Needs reinforcement 4. Not receptive Normal Diet Referred to Clinical Nutrition Services on ________________  Modified Diet Other ___________________________________________________________________  Teaching Provided Code Number Signature Patient’s Response

Patient’s Response to Teaching Session:

1. Able to perform/ verbalize

2. Unable to perform/ verbalize

Najran General Hospital | Patient and Family Education Form|

3. Needs reinforcement

4. Not receptive

PFE-001 Form A

Kingdom of Saudi Arabia Ministry of Health Directorate of Health Affairs - Najran NAJRAN GENERAL HOSPITAL

INTERDISCIPLINARY PATIENT/ FAMILY EDUCATION FORM NAME: _________________________________________________________________ FILE #: _____________________________  NATIONALITY: ________________________ AGE: __________ SEX: __________________ DEPARTMENT: _________________  5.

PAIN (Nurses/Physician) Date Time

No pain

Pain Management Referred to Physician on _____________  Other _____________________  Teaching Provided Code Number Signature Patient’s Response

Patient’s Response to Teaching Session:

1. Able to perform/ verbalize 2. Unable to perform/ verbalize 3. Needs reinforcement 4. Not receptive 6. ACTIVITY & REHABILITATION (Nurses/PT) Normal Activity Fall Prevention Referred to PT on _________  Other __________________  Date Time Teaching Provided Code Number Signature Patient’s Response

Patient’s Response to Teaching Session:

1. Able to perform/ verbalize 2. Unable to perform/ verbalize 3. Needs reinforcement 4. Not receptive 7. MEDICAL EQUIPMENT N/A Equipment given __________________ Date _________________  Referred to ____________________  Other ________________________  Date Time Teaching Provided Code Number Signature

Patient’s Response

Patient’s Response to Teaching Session:

1. Able to perform/ verbalize 2. Unable to perform/ verbalize 3. Needs reinforcement 8. MISCELLANEOUS Abduction Awareness Social Services Breastfeeding Date Time Teaching Provided

4. Not receptive Other ___________________________________  Code Number Signature Patient’s Response

Patient’s Response to Teaching Session:

1. Able to perform/ verbalize

2. Unable to perform/ verbalize

3. Needs reinforcement

4. Not receptive

Section V. Discharge Instruction Follow up appointment Emergency Care Plan of Care Discharge Medication Purpose Dosage Storage N/A Other __________________________________________________________________________________________________________ 

Patient’s Response to Teaching Session:

1. Able to perform/ verbalize

2. Unable to perform/ verbalize

Najran General Hospital | Patient and Family Education Form|

3. Needs reinforcement

4. Not receptive

PFE-001 Form A