This is me
will help you support me in hospital.
Guidance notes to help you to complete This is me
This is me is intended to provide hospital professionals with information
about you or the person you support as an individual. This will enhance the
care and support given while the person is in an unfamiliar environment or
hospital.
It is not a medical document.
This is me is about you or the person you support at the time the document is
completed and will need to be updated as necessary. It is yours or the person
that provides you with support who has responsibility to make sure all
information is accurate and up to date prior to going into an unfamiliar place or
hospital.
Things you must know about me
My name, date of birth, address and telephone number Full name and
name I prefer to be known by.
Contact person/ the person who knows me best It may be
a spouse, relative, friend or carer etc.
How to communicate with me How do I usually communicate, e.g. verbally,
using gestures, pointing or a mixture of both? Can I read and write, does
writing things down help? How do I indicate pain, discomfort, thirst or hunger?
Include anything that may help staff identify my needs.
My support needs and who gives me the most support Name of agency
and contact details, how many calls a day and what is provided. Do I need 24
hour support are family involved and what support do they provide.
Allergies Know allergies e.g. latex, plasters, types of medication, certain
foods etc
Heart/breathing problems e.g. known conditions or important information
e.g. asthma, pacemaker fitted, person gets out of breath walking up the stairs
etc
Risk of choking, dysphagia (eating, drinking and swallowing)
Recommendations or any guidelines produced by speech and language
therapist to try to prevent choking/ aspiration. Alert there is a potential for
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problems in this section but in the Amber section put what is required e.g.
needs food in puree texture, needs thickened fluids to custard consistence.
Gp details, other services/professionals involved with me e.g. names and
contact details of Community Learning Disability Nurse, Community
Psychiatric Nurse, Consultant psychiatrist, Occupational therapist, and
advocate etc.
Spiritual needs detail the person’s spiritual needs and preferences
What makes me anxious, upset or worries me? Anything that may upset
me or cause anxiety such as personal worries, e.g. money, family concerns,
or being apart from a loved one, fear of gender specific carers or physical
needs, e.g. being in pain, constipated, thirsty or hungry. Environmental needs,
noise, unfamiliar environment, I don’t like the dark.
How do I show this? What do I say? What does my facial expression or
body language look like etc?
What helps me when I feel like this? What usually reassures me, e.g.
comforting words, music or TV? Do I like company and someone sitting and
talking with me or prefer quiet time alone? Who could be contacted to help
and if so when?
Please use the notes section at the back of This is me if you need extra
space for this section.
Current medication please list medication by name, dose, route and how
many times a day the medication is taken. It is important to keep this
information accurate. You may need to bring in repeat prescription or
administration sheets which will have the most resent information.
How I take medication e.g. crushed tablets, injections, syrup. Do I take
medication on food? If person knows and prefers medication this way or it has
been decided this is in the person’s best interest.
Medical/social history and treatment plan
Medical history e.g. diagnosis, previous admission/surgery
Social/ My life so far: Place of birth, education, work history, day service,
travel, etc.
Medical Interventions how to take my blood, blood pressure give injections
etc. What will be the best way to make me less anxious and have a positive
outcome with the intervention?
Things important to me
How you know I am in pain how does the person express pain e.g. facial
expression, vocal signs, skin colour, body posture etc
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Moving around Posture in bed, walking aids, transfers, hoisting. Am I fully
mobile or do I need help? Do I need a walking aid? Is my mobility affected by
surfaces? Can I use stairs? Can I stand unaided from sitting position? Do I
need handrails? Do I need a special chair or cushion, or do my feet need
raising to make me comfortable? How many staff do I need to transfer? Do I
need reassurance/ preparation prior to hoisting?
Personal Care Normal routines, preferences and usual level of assistance
required in the bath or, shower or other. Do I prefer a male or female carer?
What are my preferences for continence aids used, soaps, cosmetics,
shaving, teeth cleaning and dentures?
Seeing/hearing Can I hear well or do I need a hearing aid? How is it best to
approach me? Is the use of touch appropriate? Do I need eye contact to
establish communication? Do I wear glasses or need any other vision aids?
How I eat and How do I drink Do I need assistance to eat or drink? Can I
use cutlery or do I prefer finger foods? Do I need adapted aids such as cutlery
or crockery to eat and drink? Does food need to be cut into pieces? Do I wear
dentures to eat or do I have swallowing difficulties? What texture of food is
required to help, soft or liquidised? Do I require thickened fluids? List likes,
dislikes (not everyone like hot/ cold drinks) and any special dietary
requirements including vegetarianism, religious or cultural needs. Include
information about my appetite and whether I need help to choose food off a
menu.
How I keep safe Do I need bed rails? Support with Challenging behaviour,
things people need to be aware of to keep me safe
How I use the toilet Does the person need prompting? Does the person
need support? What continence aids does the person use etc?
Sleeping Usual sleep patterns/ times and bedtime routines. Do I like a light
left on and do I find it difficult to find the toilet at night? Position in bed, any
special mattress, pillow, do I need a regular change of position?
My likes and Dislikes
What makes me happy? Things that are important to me, what I like to do,
what I dislike
Notes
Please add in here any important information that you were not able to put in
the document i.e. a person may have lots of anxieties and there may not be
enough space in the previous section. Please indicate in that section you
have put further information in the notes section.
Please put in topics of conversation that triggers interest and are good
items to use for staff to build up rapport or use as part of a distraction
strategy.
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