Patient Complaint Form

* = Required Information

Patient Care Directives & Visit Schedule

Patient Copy – Place in Home Folder

Agency Phone

Patient Name *

MR# *

Date of Order *

Primary Clinician *

Title

Clinician Phone

1. Authorized Clinical Care Team & Visit Frequencies

The following clinical disciplines are authorized to perform home care services. Scheduled frequencies are listed below:

Skilled Nursing (RN / LPN)

Focus: Wound care, medication management, physical assessments

Physical Therapy (PT / PTA)

Focus: Functional mobility, safety checks, fall prevention program

Occupational Therapy (OT / COTA)

Focus: ADL independence training, energy conservation, adaptive setups

Home Health Aide (HHA)

Focus: Personal care assistance, bathing support as per specialized aide plan

Other:

e.g. Medical Social Work (MSW) / Speech Therapy (ST) services

Full Medication List is updated and enclosed in the home folder.

Patient/Caregiver demonstrates independent understanding of safe medication schedules.

Additional Notes / Care Directives

Patient Individualized Emergency Plan

Keep Visible Near Phone or Bedside | Disaster Readiness & Priority Guide

Patient Name

Date of Birth

Emergency Priority Level

Emergency Contact Name

Relationship

Contact Phone

🚨 IN THE EVENT OF A LIFE-THREATENING MEDICAL EMERGENCY, CALL 911 IMMEDIATELY.
For non-emergency care adjustments or updates during a disaster, notify Agency.

1. Disaster-Specific Safety Actions

Fire Safety Plan – Primary Exit Route from Residence

Neighborhood Outdoor Meeting Location

Severe Weather / Tornado Safe Zone

Basement

Central Bathroom

Interior Room:

Medical Equipment / Power Failure Plan If electricity fails and life-sustaining equipment loses power — backup supply/plan for oxygen or infusion devices:

2. Personal Evacuation & Logistics Plan

If local emergency authorities issue a mandatory evacuation order for my area, I plan to:

Remain in the home (Only if safe, authorized by local officials, and health status allows).

Evacuate to the home of a family member or friend:

Evacuate to a local community / special needs shelter:

3. Agency Triage Protocol Notice

During a widespread community disaster, Agency will contact and prioritize clients for emergency care visits based on pre-assigned triage levels:

Level 1 (Immediate Need)	Life-sustaining equipment or highly unstable clinical condition requiring contact within 24 hours.
Level 2 (Moderate Need)	Client requiring specialized treatments or visits within 24 to 48 hours.
Level 3 (Low/Basic Need)	Client or caregiver is independent with care; safe to defer visits beyond 48 hours.

Hospitalization Prevention & Protocols Guide

Patient Health & Safety Support Sheet | Focus on Staying Safe at Home

Patient Name

MR#

Date

1. Personal Health Risks Identified at Admission

Our initial clinical assessment identified the following areas that require close proactive tracking to keep you safe and avoid unplanned hospital or emergency room visits:

History of Recent Falls, Unsteady Balance, or Home Safety Hazards

Complex, Chronic, or Slow-to-Heal Wound Profiles

Multiple Chronic Health Diagnoses (e.g., Heart Failure, COPD, Diabetes, Chronic Ulcers)

Complex Medication Profiles (High-alert medications or frequent schedule changes)

Recent Discharge from a Hospital or Skilled Nursing Facility within the past 30 days

2. Our Action Plan: Proactive Home Interventions

To address your identified risks, our clinical team is executing the following tailored safety plans:

Fall Prevention & Physical Safety: Therapy referrals initiated. Home environmental safety assessments conducted to reduce clutter and review grab bar placements.
Front-Loading Visit Patterns: Visits are intentionally scheduled closer together during the first few weeks of care to closely stabilize your symptoms and verify correct treatment compliance.
Medication Reconciliation: A licensed nurse has fully cross-checked all your prescriptions, removed outdated drugs, and provided customized teaching on warning side effects.
Physician & Care Coordination: Our interdisciplinary team communicates directly with your primary doctor to report changes early, adjusting treatment parameters before a crisis occurs.

3. Patient Symptom Zone Guide: When to Call for Help

Please use the clear boundaries below to determine when to call your home care nurse versus when to seek immediate emergency medical services:

📞 CALL AGENCY IMMEDIATELY IF YOU NOTICE:

A gradual increase in shortness of breath, cough, or sudden swelling/weight gain.
Increased redness, severe throbbing pain, foul odor, or sudden thick drainage from a wound site.
Sudden lightheadedness, a minor fall without visual injury, or increased confusion/disorientation.
Any confusion, discrepancies, or issues managing your daily medication setup.

🛑 CALL 911 IMMEDIATELY FOR EMERGENCY SERVICES IF YOU EXPERIENCE:

Severe, crushing chest pain, pressure, or sudden pain radiating down your arm or jaw.
Acute, sudden, and severe difficulty breathing that does not improve with rest or oxygen.
Signs of a stroke: sudden facial drooping, severe weakness/numbness in one arm, or slurred speech.
A severe fall resulting in a suspected fracture, uncontrollable bleeding, or inability to move.

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