Healthcare Shielding Plan Letter

HEALTHCARE SHIELDING PLAN LETTER

Patient Name:   Date of Birth:

Medical Record Number:   Effective Date:

Purpose and Scope

This Healthcare Shielding Plan Letter describes individualized administrative and clinical measures to reduce the patient’s exposure to infectious agents and other environmental hazards identified by the treating clinician. The plan supplements existing clinical orders and is intended to remain in effect for the duration specified below unless earlier modified or revoked in writing.

Patient Contact and Emergency Information

Insurance & Responsible Party

Medical History & Current Status

Shielding Plan Measures (Select applicable and provide details)

Home isolation / minimize external contacts

Visitor restrictions (who may enter residence or room)

Use of personal protective equipment (PPE) by caregivers

Designated caregiver assignments (named individuals)

Replace in-person visits with telehealth when clinically appropriate

Transportation restrictions for appointments and errands

Responsibilities and Implementation

Patient Responsibilities: the patient or authorized representative shall adhere to the measures specified in this plan, notify the clinical team promptly of new symptoms or exposures, maintain supplies as indicated in the plan, and ensure caregivers comply with PPE and visitor policies.

I acknowledge I have received clear instructions and understand how to follow the shielding measures.

Provider Responsibilities: the treating clinician and designated care team will document clinical indications for shielding measures, review the plan at scheduled intervals, provide written instructions for self-care and medication administration, and coordinate emergency care as needed.

Risks, Limitations, and Alternatives

The shielding measures selected reduce but do not eliminate the risk of infection or adverse events. Potential consequences of shielding include social isolation, delayed care for non-target conditions, and the need for additional support services. Reasonable alternatives, including adjusted clinical surveillance and different levels of restriction, have been considered and discussed with the patient when clinically appropriate.

Duration, Review and Modification

Start Date:   Planned Review Date:

The plan will be reviewed at the planned review date or sooner if the patient’s clinical status changes. The treating clinician may modify or terminate the plan in the medical record; the patient or their authorized representative may also request modification or revocation in writing.

HIPAA — Confidentiality and Disclosure

Protected health information necessary to implement this shielding plan may be shared with those individuals and agencies directly involved in the patient’s care or safety as permitted by law. The clinical team will take reasonable measures to protect confidentiality consistent with applicable privacy regulations.

Emergency Protocol

Consent and Acknowledgment

By signing below, I acknowledge that the contents of this Healthcare Shielding Plan Letter have been explained to me, that I have had the opportunity to ask questions and receive answers, and that I consent to the implementation of the shielding measures indicated above. I understand that I may revoke this consent in writing at any time, except to the extent that action has already been taken in reliance on this consent.

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