Healthcare Weekly Document

HEALTHCARE WEEKLY DOCUMENT

Patient Information

Insurance Information

Medical History (brief)

Weekly Monitoring Period

Week Start:    Week End:

Daily Monitoring (Monday — Sunday)

Monday — Date:

Symptoms (check all that apply): Fever Cough Nausea Shortness of breath None

Pain scale (0-10):    Medications taken as prescribed:

Tuesday — Date:

Symptoms: Fever Cough Nausea Shortness of breath None

Pain scale (0-10):    Medications taken as prescribed:

Wednesday — Date:

Symptoms: Fever Cough Nausea Shortness of breath None

Pain scale (0-10):    Medications taken as prescribed:

Thursday — Date:

Symptoms: Fever Cough Nausea Shortness of breath None

Pain scale (0-10):    Medications taken as prescribed:

Friday — Date:

Symptoms: Fever Cough Nausea Shortness of breath None

Pain scale (0-10):    Medications taken as prescribed:

Saturday — Date:

Symptoms: Fever Cough Nausea Shortness of breath None

Pain scale (0-10):    Medications taken as prescribed:

Sunday — Date:

Symptoms: Fever Cough Nausea Shortness of breath None

Pain scale (0-10):    Medications taken as prescribed:

Vital Signs (Most recent)

Medication Changes / Orders

Adverse Events / Incidents

Incidents this week (check all that apply): Hospitalization Fall Allergic reaction Emergency department visit None

Care Plan / Follow-up

Privacy, Authorization, and Certification

I acknowledge receipt of the facility's privacy practices and understand that protected health information may be used for treatment, payment, and health care operations. I authorize release of necessary information to the persons named below for care coordination and follow-up.

By signing below I certify that the information provided in this weekly document is complete and accurate to the best of my knowledge. I consent to weekly monitoring and to clinically indicated interventions consistent with my care plan. I understand I may revoke this authorization in writing at any time; revocation will not affect actions taken in reliance on this authorization prior to receipt of the revocation. Exceptions to confidentiality include mandatory reporting for communicable diseases, abuse, or imminent risk of harm as required by law.

HIPAA Privacy Practices acknowledged:

Signature below attests to the foregoing statements and constitutes written authorization for release and use of health information as indicated above for the duration specified.

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