Healthcare AFC Protocol

HEALTHCARE AFC PROTOCOL

Facility Name:    Protocol ID:    Effective Date:

Patient Information

Emergency Contact

Insurance Information

Admission and Placement

Admission Date:    Room/Bed:    Admitting Clinician:

Medical History and Current Status

Medication Management

Medications listed below are authorized for administration per prescriber orders. Staff must confirm name, dose, route, time, and special instructions before administration.

PRN (as needed) medication orders: staff shall document indication, time administered, dose, and response in the medical record. Standing PRN criteria and monitoring instructions are required for each PRN medication.

Behavioral Supports & Seclusion/Restraint

Behavioral support plan on file: Yes    Crisis de-escalation techniques authorized: Yes

Seclusion or physical restraint shall be used only when immediate risk of harm is present and when less restrictive alternatives have failed. All uses must be documented with rationale, duration, staff involved, and post-event review.

Emergency and Transport Protocol

Resuscitation Status (e.g., Full Code, DNR):    Advance Directive on file: Yes

Infection Control

Staff Responsibilities and Training

Staff training requirements: all staff assigned to this patient shall have documented competency in medication administration, infection control, emergency response, and behavioral de-escalation. Completion dates and competency records will be maintained in the personnel file.

Patient Rights, HIPAA & Authorization

I acknowledge receipt of and understand the AFC Protocol provisions set forth in this document. I understand my rights regarding privacy of protected health information and the use and disclosure of such information for purposes of care coordination, treatment, payment, and facility operations as required for delivery of services under this protocol.

I authorize the disclosure of my relevant health information to individuals and entities involved in my care as necessary to implement this AFC Protocol, including but not limited to physicians, pharmacies, emergency services, and authorized family members or representatives as indicated below.

This authorization is valid until: . I understand I may revoke this authorization at any time by providing written notice, except to the extent that action has already been taken in reliance upon this authorization.

By signing below I consent to the implementation of the AFC Protocol, including medication administration, routine and emergency medical treatment, behavioral interventions as specified, and necessary disclosures to coordinate my care. I confirm that the information provided on this form is accurate to the best of my knowledge.

Certification by Patient or Authorized Representative

I certify under penalty of law that the foregoing is true and correct and that I have the authority to execute this Protocol for myself or the patient named herein.

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