This is my health passport
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- Lesley Carroll
- 6 years ago
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1 This is my health passport This leaflet will help you to support me in an unfamiliar place My name is: This document gives health staff important information about me. This passport belongs to me. It needs to go beside my bed and a copy should be put in my notes. Please return it when I am discharged. M. Please read my passport Consider the reasonable adjustments you need to make Involve family and carers as they often know the person best. Things you must know about me Things that are important to me My likes and dislikes Mental Capacity Act Please do not assume that I do not have mental capacity. The following people must be involved in any decisions made in my best interests. Please be aware of any advanced decision Lasting Power of Attorney, Court of Protection Name Relationship Contact details
2 Things you must know about me My name: I like to be known as: NHS number: Date of birth: My address and Telephone number I live: with family in supported living in a residential home on my own in a nursing home How I communicate and how to communicate with me: What languages I speak: Seeing/hearing (my sight or hearing needs): 2
3 Things you must know about me My family contact person: Relationship eg mother, father: Address: Telephone number: Other support: Relationship e.g. support worker, home manager: Company address: Telephone number: Name of person/people you need to contact on discharge: Relationship: Telephone number: Address: Religion and religious/spiritual needs: Ethnicity: 3
4 Things you must know about me GP: Address: Telephone number: Other services/professionals eg social workers, nurses etc: My allergies: My medical history: 4
5 Things you must know about me My heart / breathing problems: My risk of choking (eating, drinking and swallowing problems): How I take my medication bring in most recent medication list: whole tablets other crushed injections syrup How to take my blood, give injections, give medication, take my blood pressure, etc: 5
6 Things you must know about me What makes me anxious or afraid (risks to me and others). How you can support me: My sensory reactions and how you can help (under/over sensitive to light, noise, touch, smell, taste): How you know I am in pain: 6
7 Things that are important to me Help I need with personal care (dressing, washing, etc): How I eat and I drink (help I need, PEG, food cut up, pureed, risk of choking, drink small amounts, thickened fluids, bring in eating and drinking guidelines): How I use the toilet (aids, help to get to toilet): 7
8 Things that are important to me How I move around (my position in bed, walking aids, use of hoist): My sleep routine (sleep pattern/ equipment): How I keep safe (bed rails, risk of falls, wandering, can I call for help): 8
9 My likes and dislikes Likes: for example what makes me happy, things I like to do, such as watching TV, reading, music, routines. Dislikes: for example do not shout, food I do not like, physical touch. Things I like Please do this Things I do not like Please do not do this 9
10 Notes You can add any information you think we need to know, it might include: what help your family member or carer may want to give when in hospital (help eating, drinking, personal care, stay overnight ) more information on how we support you. Any other reasonable adjustments to care that we may need to make you ensure you are safe and get the best care. Patient Advice and Liaison Service (PALS) PALS can provide information and support to patients and carers and will listen to your concerns, suggestions and queries. The service is available between 9am and 5pm. Telephone: Textphone: pals@homerton.nhs.uk This passport was completed by Date This hospital passport was developed by Homerton University Hospital NHS Foundation Trust and is based on original work by St George s Healthcare NHS Trust, Barts Health and Basildon and Thurrock University Hospitals NHS Foundation Trust. We would also like to thank POhWER for their support in producing this hospital passport Produced by: Learning Disabilities Nurse Specialist (Acute) Date produced: June 2015 Review date: June
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