Hospital Grab Sheet Incorporating This Is Me Endorsed by the Royal College of Nursing and the Alzheimer s society
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1 Patient Experience Patient Information Hospital Grab Sheet Incorporating This Is Me Endorsed by the Royal College of Nursing and the Alzheimer s society RED AMBER GREEN Information sharing How to communicate with me Please complete this Grab Sheet and give it to the hospital staff who are providing your care. It will give them important information about how care is provided for you at home. Please ask the hospital staff to read it and place this Grab Sheet in your patient medical records file. My name: Signature/stamp Completed by: Relationship: Date form completed: / / Hospital number: (if known) This Grab Sheet belongs to the patient. It should be returned to them on discharge from hospital or a new Grab Sheet should be provided. New Grab Sheets are available from the Patient Experience, leaflet A-Z, section of the intranet. Template version: December 2010 Hospital Grab Sheet 1
2 RED ALERT THINGS YOU MUST KNOW ABOUT ME My name: (The name I like to be known by) My current address: GP: GP address: My Tel. No: My date of birth: My religion: My next of kin: Relationship: Tel. No: My key worker/main carer/person I know best: Relationship: Tel. No: Professionals/other agencies involved: including the type of carer support I currently receive How involved I would like my carer to be whilst I am in hospital: : Tel. No: I have allergies to: Template version: December 2010 Hospital Grab Sheet 2
3 My current medication: My current medical conditions are: e.g. heart or respiratory problems and a brief medical history My behaviours that may be challenging or cause risk: My medical interventions: (how to take my blood, give injections, take my temperature, give medication, blood pressure, etc.) Template version: December 2010 Hospital Grab Sheet 3
4 AMBER ALERT THIINGS THAT ARE REALLY IMPORTANT TO ME My level of support: (Carer with me day/night? Support needed by me or my carer from ward staff?) My personal care: (Dressing, washing, etc., care of my mouth/teeth) Pain: (How you know I am in pain) How I take medication self-medication with carer/assistants: (Tablets, injections, syrup, mediboxes) Moving around: (Posture in bed, wheelchair, walking aids) Eating: (Swallowing, choking, help with feeding, cut up food, small amounts) Drinking: (Swallowing, choking) Going to the toilet: (I use continence aids, need help to get to the toilet) Sleeping: (My sleep pattern, sleep routine) Seeing/hearing: (I wear glasses, hearing aids) Keeping safe: (Bedside, absconding) Template version: December 2010 Hospital Grab Sheet 4
5 GREEN THINGS I WOULD LIKE TO HAPPEN (LIKES/DISLIKES) Please consider the following list. Your answers/suggestions will help the staff to care for you when you are in hospital: What makes me happy What upsets me Things I would like you to know about my family People or places I may refer to The area where I live What I like to do, i.e. how I like to relax, watching TV, reading, music How I want to be talked to (don t shout) Food I like. Food I don t like Physical touch, special needs, my routine Things that keep me safe Any other information you need to know about me Please feel able to bring in any small items which may help or comfort the person during their stay in hospital. However please declare these and any additional items brought in at a later date to the staff for documenting. Template version: December 2010 Hospital Grab Sheet 5
6 Contact details Patient Advice and Liaison Service Tel: For further general health-related information, please ask the relevant department for an Information Prescription or contact: The Health Information Centre Poole Hospital NHS Foundation Trust Longfleet Road Poole Dorset BH15 2JB Telephone: Author: Amanda Colman Date: June 2011 Review Date: June 2014 Version Number: 2 Ward sister/hod: Head of Patient Experience We can supply this information in other formats, larger print, on audiotape, or have it translated for you. Please call the Patient Advice and Liaison Service (PALS) on or the Health Information Centre on for further advice. Template version: December 2010 Hospital Grab Sheet 6
Please take it with you if you have to go into hospital. Make sure that all the staff who need to know about the information read it
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