** Bring this Plan to ALL Appointments**
After Hospital Care Plan for: ___________________________
(Patient Name)
Discharge Date: ___________________
Questions about the information in this packet? Call your Care Manager: ____________________
(603) _______________
Feeling worse or getting sicker? Call your Provider: Dr. _______________
(603) ______________
If you are experiencing a Medical Emergency then call 911
Your Primary Medical Condition:
 Congestive Heart Failure





Poor Pumping Heart
Decreases blood circulation
Causes Shortness of Breath
Causes swelling in Lower Legs
To stay well you must:
 Take all medications as prescribed
 NOT SMOKE
 Follow diet recommendations
 Weigh yourself daily
 Keep all doctor’s appointments
 Ask your doctor questions
 Chronic Obstructive
Pulmonary Disease (COPD)
Damaged Lungs
 Can experience
 shortness of breath
 chest tightness
 coughing& or wheezing
 Difficulty sleeping laying flat in
bed.
 To stay well you must:
 Take all medication as prescribed
 NOT SMOKE
 Follow activity recommendations
 Keep all doctor’s appointments
 Ask your doctor questions
Your Primary Medical Condition:
 Pneumonia
 Infection in your lungs and or
upper breathing airways.
 Causes shortness of breath
 Causes Coughing and phlegm
To Stay well you must:
 NOT SMOKE
 Take all Medications as
prescribed
 Take all antibiotics until
they are gone.
 Follow up with your
doctor to check your
status so the infection does
not return.
 Diabetes
 Your body is not able to handle your blood sugar
(low insulin production)
 Your body is not able to use the insulin you are
making (poor cell absorption)
 Uncontrolled blood sugar can cause
 Damage to kidneys and problems making pee
 Damage to eye and blindness
 Numbness and pain in legs and feet
 Problems in blood circulation
 To Stay well you must:
 Take medications as prescribed
 NOT SMOKE
 Check your blood sugars and write down the
information for your doctor.
 Follow the diet recommended
 Follow the activity level recommended
 Keep all doctor’s appointments
***BRING ALL YOUR MEDICATIONS TO EVERY
APPOINTMENT***
In a bag bring all your medication that you are currently taking to each appointment.
This includes:
 Pills, capsules and tablets
 Inhalers or other respiratory treatment
 Insulin’s and other inject able medications
 Vitamins and other supplements
 Herbal Medications
 Other over the counter medications
Your doctor or the nurse will review these with you and make sure
you are taking them right.
EACH DAY you need to follow this schedule:
MEDICINES
What time of day do I take
this medicine?
MORNING
Why am I taking this
medicine?
Medicine Name and the
amount.
How many or how much
do I take?
How do I take this
medicine?
What time of day do I take
this medicine?
Afternoon
Why am I taking this
medicine?
Medicine Name and the
amount.
How many or how much
do I take?
How do I take this
medicine?
What time of day do I take
this medicine?
Evening
Why am I taking this
medicine?
Medicine Name and the
amount.
How many or how much
do I take?
How do I take this
medicine?
What time of day do I take
this medicine?
Bedtime
Why am I taking this
medicine?
Medicine Name and the
amount.
How many or how much
do I take?
How do I take this
medicine?
** Bring this Plan to ALL Appointments**
What is my main medical problem?
 Congestive Heart Failure (poor pumping heart)
 COPD (Lung damage & Shortness of Breath)
 Pneumonia – (Lung/Respiratory Infection)
 Diabetes – (poor blood sugar control)
When are my Next Appointments?
Date and Time of
Appointments
Provider Name:
Where is
appointment?
(location)
Reason for
appointment?
Provider’s Phone
Number
Date:
Time:
Date:
Time:
Date:
Time:
What exercises are good for me?
 Walking is a very healthy form of exercise. Please do your best to walk for at least _____ minutes every
day.
 Other: ________________________________________________________________________________________________________
What should I eat?




Eating food that is low in fat and low in cholesterol will help you stay healthy.
Eating foods low in salt will help you avoid swelling or shortness of breath.
Avoid sweetened foods and drinks to help manage healthy blood sugar levels. Use sugar substitutes.
Other: ___________________________________________________________________________________________________
What are my medication allergies?
REMEMBER you are allergic to:
___________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Where is my pharmacy?
Pharmacy Name: ______________________________________________________________________________________
Address: _______________________________________________________________________________________________
Phone Number: ________________________________________________________________________________________
What else should I do to stay well?
 Weigh yourself everyday and call your doctor if you have a 2 pound or more weight gain in one day.
 Do Not Smoke. Assistance is available by asking your doctor.
 Call your provider if you have any changes that make you feel worse or sicker.
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Questions / Concerns
For my appointment with
Dr. ___________________
Check the box and write notes to remember what to talk about with Dr. ______________________
I have questions about:
my medicines ________________________________________
my pain _____________________________________________
feeling stressed ________________________________________
smoking______________________________________
What other questions do you have? ___________________________
________________________________________________________
________________________________________________________
________________________________________________________