Healthcare Nursing Packet

HEALTHCARE NURSING PACKET

Patient Information

Date of birth:    Gender: Male Female Other/Prefer not to say

Emergency Contact

Insurance Information

Medical History & Current Status

Height:    Weight:    Preferred Pharmacy:

Nursing Assessment (to be completed by nursing staff)

Presenting complaint / reason for nursing visit:

Pain level (0-10):    Mobility concerns: None Requires assistance Ambulatory with device

Skin integrity concerns: None Pressure ulcer Other    If other, describe:

Consent for Nursing Services

I authorize licensed nursing personnel to provide nursing assessment, treatment, and interventions as prescribed by the attending provider. Nursing services may include medication administration, wound care, vital signs monitoring, injections, specimen collection, education, and other routine nursing interventions consistent with the plan of care.

I understand that nursing care involves potential risks, including but not limited to medication side effects, allergic reactions, infection at a procedure site, bleeding, or other unanticipated adverse outcomes. The anticipated benefits, risks, and alternatives have been explained to me and I have had the opportunity to ask questions and receive answers to my satisfaction. I may withdraw this consent at any time, except to the extent that action has already been taken in reliance on this consent.

Authorization to Release Information

I authorize the release of my protected health information to other healthcare providers, facilities, payers, or their agents as necessary for treatment, payment, and health care operations related to the services provided. This authorization includes clinical notes, medication records, laboratory results, and imaging reports unless specifically excluded in writing below.

This authorization will expire on:

HIPAA Privacy Acknowledgment

I acknowledge receipt of the facility's Notice of Privacy Practices. I understand that my protected health information will be used and disclosed in accordance with that notice and applicable law. I understand that I may request restrictions on certain uses and disclosures, and that such requests must be made in writing.

I acknowledge receipt of the Notice of Privacy Practices

Advance Directives

Do you have any advance directive (e.g., living will, durable power of attorney for healthcare)? Yes No

Patient Rights & Responsibilities

The patient has the right to be informed about the care being provided, to participate in decisions, to refuse treatment, and to access their medical record as permitted by law. The patient is responsible for providing accurate medical history and reporting changes in condition, complying with treatment plans, and providing payment or insurance information as required.

Acknowledgments & Certification

By signing below, I certify that the information provided on this nursing packet is true to the best of my knowledge. I consent to the nursing services described above and authorize release of my health information as indicated. I understand that I may revoke authorizations in writing except to the extent actions have already been taken in reliance on this authorization.

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