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Patient & Family Education Form

This patient education form documents the health education provided to a patient during their admission, treatment, and discharge from the hospital. It includes topics like diagnosis, treatment plan, medication management, infection control, and follow-up care. The form tracks the teaching methods used, outcomes of the education, and is signed by the nurse, patient, and attendant.

Uploaded by

Soloman Kumar
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We take content rights seriously. If you suspect this is your content, claim it here.
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3K views3 pages

Patient & Family Education Form

This patient education form documents the health education provided to a patient during their admission, treatment, and discharge from the hospital. It includes topics like diagnosis, treatment plan, medication management, infection control, and follow-up care. The form tracks the teaching methods used, outcomes of the education, and is signed by the nurse, patient, and attendant.

Uploaded by

Soloman Kumar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Patient & Family Education Form

Date: - _________________ Diagnosis: - ____________________________________


Health Education given to Patient Attendant

At Time of Admission: - Date:-

During Treatment:-

Health Education Topics Teaching Method Outcomes Name & Signature of Patient/
(write the topic in others Signature of SN Attendant
if not mentioned)

Diagnosis

Patient right &


Responsibilities
Scope of services
Treatment Plan
Environment awareness

Patients Valuable

Health Education Date & time Teaching Method Outcomes Name & Signature of Patient/
Topics (write the topic Signature of RN Attendant
in others if not
mentioned)

Pain Management
Fall Prevention

Nutritional Need

Consents for
procedure
Vulnerable Patient
care
Food & drug
Interaction
Infection Control
Practices
Catheter/ Toiletry Care

Safe use of equipment

Others
At the time of Discharge:- Date: - Time: -

Health Education Topics Teaching Method Outcomes Name & Signature Signature of Patient/
(write the topic in others if not of RN Attendant
mentioned)

Discharge Summery

Medications

Drug Interaction

Care of Surgical Site

Insulin Therapy

Infection Control
Practices
Feeding Practices

Tracheostomy Care

Catheter/ Toiletry Care

Physiotherapy Care

In case of emergencies

Follow up care

Others

Patient Queries/ Question Answer: -


……………………………………………………………………………………....................................................

…………………………………………………………………………………………………………………………………………………………………………………………
…….

…………………………………………………………………………………………………………………………………………………………………………………………
…….

…………………………………………………………………………………………………………………………………………………………………………………………
……..

Teaching Method:- Demonstration, Discussion, Handouts


Outcomes:- Demonstrates acceptable level of knowledge; Requires additional instructions then Specify
details.

NAME SIGNAURE DATE TIME

Nurse ………………………………………………………… ………………………….. ……………………………… ………………….

Patient ………………………………………………………… ………………………….. ……………………………… ………………….


Attendant ………………………………………………………… ………………………….. ……………………………… ………………….

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