Implementing High Quality Telephone Care in Pediatric Practice 12/28/10

This presentation, available in audio and slideshow formats, provides pediatricians and their staff with information about the use of telephone care in pediatric practice, citing examples for the management of chronic diseases such as asthma. Associated handouts available for download include sample telephone care plans and forms for selected conditions.

This presentation is part of a series provided by the Quality Improvement Innovation Network, a program of the American...

POLST (Physician Orders for Life-Sustaining Treatment) 09/10/10

POLST (Physician Orders for Life-Sustaining Treatment) is a form that states what kind of medical treatment patients want toward the end of their lives. It is intended to help give seriously ill patients more control over their end-of-life care.

The POLST form and its related resources, including a brochure and videos, are available in multiple languages.

Care Coordination Forms 09/08/10

The New York Care Coordination Program is a collaborative partnership among State and county governments, peers and family members, and mental health provider agencies. The program offers person-centered, recovery-focused care coordination for individuals with severe mental illness (e.g., schizophrenia, bipolar disorder, clinical depression) who have had at least one psychiatric hospitalization.

This site provides downloadable versions of the forms used by the program’s care...

Asthma Action Plan 04/29/09

Patients can use this template with their doctor to help manage their asthma on a daily basis and during an attack. It also includes a list of possible asthma triggers and ways to avoid them.

This action plan is divided into color-themed zones with which the health care provider can indicate specific instructions for when the patient is doing well (green), getting worse (yellow), or needs medical assistance (red). Each section lists the following types of information:

Patient Encounter Form 04/08/09

This form can be used as a model for clinicians to establish a reminder system to improve quality measures and goals.

Patient visits can be guided by this customizable patient encounter form that is designed to incorporate a practice’s quality goals and measures. It can be printed automatically at patient arrival, manually on demand, or completed using a real-time Web interface.

In addition to documenting services due, diagnoses and problems, and actions taken, the...

Self-Management Support: Patient Planning Worksheet 12/17/07

This form may be used by patients either at home or during their office visit to plan their self-management goals for managing their chronic illness.

Free registration is required.

Prototype for Medical Facility Orders During a Radiation Event 12/17/07

This tool is a prototype form that can be customized to document the assessment and treatment of adult patients exposed to radiation.

This form provides space to record the following types of information:

  • Diagnosis
  • Condition
  • Vital signs
  • Special orders for radiation contamination
  • Allergies
  • Activity
  • Diet
  • Height and weight
  • Peripheral IV management
  • Foley catheter management
  • Monitor intake/...
My Medication Record 12/17/07

Patients can use this form to keep track of all their medicines and supplements. Patients are encouraged to show it to their doctors and pharmacist at each visit and ask them to check for unnecessary duplications or medicines that could interact to cause harm.

This form includes the following fields to be completed by the patient:

  • Name of medicine or product
  • How much do I take?
  • When and how do I take it?
  • Why do I take it?
  • Start...
Keep It With You: Personal Medical Information Form 12/17/07

This form is intended to be a voluntary and temporary record that lists medical care and other health information for people who need care during disasters and similar situations. This form can assist health care workers to learn information about past and new health concerns for people receiving help.

Patients fill out as much information on the form as they can, and staple their immunization card listing the shots they have recently received to the form.

Information recorded on...

Asthma Action Plan 11/29/07

The Asthma Action Plan is a one-page form that the doctor and patient can complete together. It provides information and instructions for patients’ self-management of asthma and includes space for the doctor to fill in directions for medication, peak flow numbers, asthma triggers, and what to do in case of an asthma attack or an emergency.


This website is certified by Health On the Net Foundation. Click to verify. This site complies with the HONcode standard for trustworthy health information: verify here.