Document 15055928

Appendix H: Concerned- Uncomfortable- Safety (CUS) Communication Tool
Minnesota Antimicrobial Stewardship Program Toolkit for Long-term Care Facilities
I am Concerned about my resident's condition.
I am Uncomfortable with my resident's condition.
I believe the Safety of the resident is at risk.
I am concerned that:
[Describe your concern about the resident]
I am uncomfortable with:
[Explain why you’re concerned about the resident]
I believe:
[Describe why the safety of the resident is at risk]
Minnesota Department of Health
Infectious Disease Epidemiology, Prevention and Control Division
Adapted from Module 2: Communicating Change in a Resident's Condition: Improving Patient Safety in Long-Term
Care Facilities. June 2012. Agency for Healthcare Research and Quality, Rockville, MD.