The agency that accredits hospitals typically informs facilities that they are coming for a visit in advance. This allows administrators to have time to staff the units appropriately and clean the areas for inspection. It has been my observation that this agency rarely makes surprise visits. Hospitals spend billions of dollars lobbying our government to keep healthcare from being regulated. This means no one is watching how they take care of you or your loved one. This guide will help inform you of how to protect yourself from negligence, hospital-acquired infections, inflated billing, and possible wrongful death. It will assist you in understanding various tests, scans, procedures, and medical language.

You need to protect yourself by always asking questions and documenting everything. Take charge of your healthcare. Remember that without you, they would be out of business. You do have choices. If you do not approve of the care that is being provided inform the chief nursing officer, case manager, and social worker. Do not settle for substandard care.

Have you or your loved ones ever been a patient in the hospital or a nursing home? Have you found yourself agreeing with whatever test or procedure the physician orders only to feel frustrated due to lack of understanding of the purpose for the test? Have you felt as if your healthcare providers are speaking a different language?

Patient Empowerment Guide and Journal provides you with the tools that you will need to understand the various tests, scans, procedures, and medical language that is used by your healthcare providers. It includes a written legal journal of what, when, and how activities should be performed. This guide will assist you in reducing the possibility of a hospital-acquired infection, give you a greater understanding of the tests and procedures that are being prescribed for you, and possibly protect your life.

Patient Empowerment Guide and Journal

The Thirty-Day Planner, Organizer, and Journal for Your Inpatient VisitBy Johnilynn Wunderlich

iUniverse, Inc.

Copyright © 2009 Johnilynn Wunderlich
All right reserved.
ISBN: 978-1-4401-7169-7

Contents

MY HOSPITAL JOURNAL.........................................................1MY INSURANCE INFORMATION....................................................2MAKING DECISIONS............................................................3PRIVACY CODE................................................................4MEDICATION LIST.............................................................5MEDICATION LIST.............................................................6LIST OF SURGERIES AND PROCEDURES............................................7LIST OF PHYSICIANS AND THEIR SPECIALTY......................................8ITEMIZED BILLING............................................................10OBTAINING MEDICAL RECORDS...................................................11KEEP YOUR EYES OPEN.........................................................12NOSOCOMIAL INFECTIONS.......................................................14INFORMATION REGARDING ADMINISTERING BLOOD PRODUCTS..........................16RECORD OF BLOOD PRODUCTS....................................................17MEDICAL IMAGING.............................................................18INFORMATION REGARDING CONTRAST MEDIA........................................20ROUTES OF OXYGENATION.......................................................21FACTS REGARDING MECHANICAL VENTILATION......................................22MY VENTILATOR SETTINGS......................................................24REHABILITATION THERAPIES....................................................25THERAPY SCHEDULE CONTINUED FROM _______ TO ________.........................26DIALYSIS....................................................................28MY DIALYSIS SCHEDULE........................................................30TYPES OF NUTRITION..........................................................32MY NUTRITION SCHEDULE.......................................................35BASIC UNDERSTANDING OF COMMON LAB TESTS.....................................45IT'S ALL GREEK TO ME ... UNDERSTANDING MEDICAL LANGUAGE.....................50ENTERING THE EMERGENCY ROOM.................................................79MY CANCER JOURNAL...........................................................351SPECIAL DELIVERY............................................................368MEDICAL SUPPLY LIST FOR ___ DATES ___ TO _______............................372Index.......................................................................377

Chapter One

MY HOSPITAL JOURNAL

This journal belongs to: ________________________

I stayed at ________________________ hospital.

Dates of my stay: _____________________

My reason for coming to hospital: ___________________ _____________________________________________________

My diagnosis: _______________________________________ _____________________________________________________

My physician's names: _______________________________ _____________________________________________________

My day shift nurses names: __________________________ _____________________________________________________

My night shift nurses names: ________________________ _____________________________________________________

My patient care technician's names: _________________ _____________________________________________________

Names of charge nurses: _____________________________ _____________________________________________________

Name of case manager: _______________________________

Name of social worker: ______________________________

Name of nurse manager: ______________________________

Names of nursing supervisors: _______________________

Name of inpatient service director: _________________

Name of chief nursing officer: ______________________

Name of CEO at hospital: ____________________________

This hospital is owned by ______________ Corporation.

Is this a for profit hospital: _____ yes, _____ no.

MY INSURANCE INFORMATION

My primary insurance company is: ______________________________

My policy number is: _______________ Group number: ____________

My ID number is: ___________ Insurance phone number: _________

Mailing address of insurance company: _________________________ _______________________________________________________________

I am the primary/secondary (circle) policy holder.

If secondary policy holder, name of primary: __________________

My co-pays are: _______________________________________________

Do all my physicians take my insurance that see me during my

hospital stay: _____ yes, ____ no. This is important to ask.

My secondary insurance company is: ____________________________

My policy number is: _______________ Group number: ____________

My ID number is: ___________ Insurance phone number: __________

Mailing address of insurance company: _________________________ _______________________________________________________________

I am the primary/secondary (circle) policy holder.

If secondary policy holder, name of primary: __________________

My co-pays are: _______________________________________________

Notes: ________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________

MAKING DECISIONS

There are times when we need to make our decisions known in advance. Spending time in the hospital setting is one of those times. I have witnessed all too often patients suffer needlessly due to not having made these important wishes clarified in writing.

If you do not currently have these in place, I strongly urge you to complete them before you come into the hospital. If this is not possible, the hospital can assist you with them. Do not hesitate to ask!

I have a Living Will: ____ yes, ____ no.

Copy given to the hospital: _____ yes, _____ no.

Is a copy on the chart (ask)! ____ yes, _____ no.

I would like information regarding a Living Will: _____ yes, _____ no.

I have a Healthcare Surrogate: ________ yes, ______ no.

If yes, name of person: _____________________________

If no, I wish to initiate __________________________ as my Healthcare Surrogate if I am unable to become unable to make my own decisions.

Copy given to hospital: _____ yes, _____ no.

Is a copy on the chart (ask)! _____ yes, _____ no.

I would like information regarding the responsibilities of my Healthcare Surrogate: ____ yes, _____ no.

If yes, ask for the form from the hospital and have your healthcare provider explain it to you.

I have a Medical Power Of Attorney: _____ yes, _____ no.

My medical power of attorney is: ____________________________________

Their contact information is: _______________________________________ _____________________________________________________________________

Copy given to the hospital: _____ yes, _____ no.

Is a copy on the chart (ask)! _____ yes, _____ no.

I would like information regarding the responsibilities of my Power Of Attorney: _____ yes, _____ no.

If yes, ask for the form from the hospital and have your healthcare provider explain it to you.

TERMS TO KNOW

Full Code: This is where every attempt is made to save a patient during cardiopulmonary arrest. This includes but not limited to: medications, chest compressions, electrical shocks to the heart, intubation and line insertions.

DNR or Do Not Resuscitate: You will be cared for as any other patient. If your heart or lungs fail, then we allow nature to take its course and provide comfort to the patient.

CMO or Comfort Measures Only: This is when it has been determined that the end of life is inevitable. IV fluids, nutrition, and medications are stopped. Pain medications are allowed.

PRIVACY CODE

There are federal laws that protect your privacy. The Health Insurance Portability and Accountability Act of 1996 is known as HIPAA. It is important to understand that in accordance with the law healthcare professionals are not allowed to discuss your condition or that you are patient with anyone that does not have your privacy code.

Note: It is strongly suggested that one main contact person be named and that everyone else contact that individual for updates. Nursing staff are very busy giving patient care and too many updates take time away from the patients.

My privacy code: ___________ Name of primary contact: ______________

The following persons are allowed to have my privacy code and information regarding my condition:

Name: ______________ Home phone: _____________ Work: ______________ Cell: ___________________

Name: ______________ Home phone: _____________ Work: ______________ Cell: ___________________

Name: ______________ Home phone: _____________ Work: ______________ Cell: ___________________

Name: ______________ Home phone: _____________ Work: ______________ Cell: ___________________

Name: ______________ Home phone: _____________ Work: ______________ Cell: ___________________

Name: ______________ Home phone: _____________ Work: ______________ Cell: ___________________

Name: ______________ Home phone: _____________ Work: ______________ Cell: ___________________

MEDICATION LIST

I take (medication name) _____, dosage amount ______ How many times per day _____ at what times ______ Purpose for medication __________

I take (medication name) _____, dosage amount ______ How many times per day _____ at what times ______ Purpose for medication __________

I take (medication name) _____, dosage amount ______ How many times per day _____ at what times ______ Purpose for medication __________

I take (medication name) _____, dosage amount ______ How many times per day _____ at what times ______ Purpose for medication __________

I take (medication name) _____, dosage amount ______ How many times per day _____ at what times ______ Purpose for medication __________

I take (medication name) _____, dosage amount ______ How many times per day _____ at what times ______ Purpose for medication __________

I take (medication name) _____, dosage amount ______ How many times per day _____ at what times ______ Purpose for medication __________

I take (medication name) _____, dosage amount ______ How many times per day _____ at what times ______ Purpose for medication __________

I take (medication name) _____, dosage amount ______ How many times per day _____ at what times ______ Purpose for medication __________

I take (medication name) _____, dosage amount ______ How many times per day _____ at what times ______ Purpose for medication __________

I take (medication name) _____, dosage amount ______ How many times per day _____ at what times ______ Purpose for medication __________

I take (medication name) _____, dosage amount ______ How many times per day _____ at what times ______ Purpose for medication __________

I take (medication name) _____, dosage amount ______ How many times per day _____ at what times ______ Purpose for medication __________

I take (medication name) _____, dosage amount ______ How many times per day _____ at what times ______ Purpose for medication __________

I take (medication name) _____, dosage amount ______ How many times per day _____ at what times ______ Purpose for medication __________

I take (medication name) _____, dosage amount ______ How many times per day _____ at what times ______ Purpose for medication __________

I take (medication name) _____, dosage amount ______ How many times per day _____ at what times ______ Purpose for medication __________

I take (medication name) _____, dosage amount ______ How many times per day _____ at what times ______ Purpose for medication __________

I take (medication name) _____, dosage amount ______ How many times per day _____ at what times ______ Purpose for medication __________

I take (medication name) _____, dosage amount ______ How many times per day _____ at what times ______ Purpose for medication __________

I take (medication name) _____, dosage amount ______ How many times per day _____ at what times ______ Purpose for medication __________

I take (medication name) _____, dosage amount ______ How many times per day _____ at what times ______ Purpose for medication __________

I take (medication name) _____, dosage amount ______ How many times per day _____ at what times ______ Purpose for medication __________

I take (medication name) _____, dosage amount ______ How many times per day _____ at what times ______ Purpose for medication __________

I take (medication name) _____, dosage amount ______ How many times per day _____ at what times ______ Purpose for medication __________

I take (medication name) _____, dosage amount ______ How many times per day _____ at what times ______ Purpose for medication __________

I take (medication name) _____, dosage amount ______ How many times per day _____ at what times ______ Purpose for medication __________

I take (medication name) _____, dosage amount ______ How many times per day _____ at what times ______ Purpose for medication __________

LIST OF SURGERIES AND PROCEDURES

I had __________ (Surgery/Procedure) Reason: ________ Year: __________, Physician: _____

I had __________ (Surgery/Procedure) Reason: ________ Year: __________, Physician: _____

I had __________ (Surgery/Procedure) Reason: ________ Year: __________, Physician: _____

I had __________ (Surgery/Procedure) Reason: ________ Year: __________, Physician: _____

I had __________ (Surgery/Procedure) Reason: ________ Year: __________, Physician: _____

I had __________ (Surgery/Procedure) Reason: ________ Year: __________, Physician: _____

I had __________ (Surgery/Procedure) Reason: ________ Year: __________, Physician: _____

I had __________ (Surgery/Procedure) Reason: ________ Year: __________, Physician: _____

I had __________ (Surgery/Procedure) Reason: ________ Year: __________, Physician: _____

I had __________ (Surgery/Procedure) Reason: ________ Year: __________, Physician: _____

I had __________ (Surgery/Procedure) Reason: ________ Year: __________, Physician: _____

I had __________ (Surgery/Procedure) Reason: ________ Year: __________, Physician: _____

I had __________ (Surgery/Procedure) Reason: ________ Year: __________, Physician: _____

I had __________ (Surgery/Procedure) Reason: ________ Year: __________, Physician: _____

LIST OF PHYSICIANS AND THEIR SPECIALTY

This is a list of the different types of physicians that may see you during your hospital stay:

You will always have a Primary Physician (also called Attending Physician, this is the doctor in charge of your care.)

Check and list names of the physicians that apply to you during your hospitalization. __________

__Primary: Dr.______________

__Allergist (allergies): Dr._________ __Anesthesiologist (pain control, puts you to sleep and monitors during procedures): Dr: __________

__Cardiologist (heart): Dr. __________

__Dermatologist (skin conditions): Dr. __________

__Endocrinologist (hormones, diabetes, thyroid): Dr. __________

__ENT (ear, nose, throat): Dr. __________

__Gastroenterologist (stomach, intestines, liver): Dr. __________

__Gynecologist (female reproductive system): Dr. __________

__Hematologist (blood disorders): Dr. __________

__Infectious Disease: Dr. __________

__Internal Medicine: Dr. __________

__Neonatologist (premature infants): Dr: __________

__Nephrologist (kidneys and urinary tract): Dr. __________

__Obstetrician (pregnancy, childbirth, and post partum): Dr: __________

__Oncologist (cancer): Dr. __________

__Ophthalmologist (diseases of the eye): Dr. __________

__Optometrist (eyes, vision correction): Dr. __________

__Orthopedist (bones, joints): Dr.____________

__Pediatrician (children): Dr. _______________

__Proctologist (disorders of the rectum or anus): Dr. __________

__Psychiatrist/psychologist (mental health): Dr. _______________

__Pulmonologist: (lungs and ventilator management): Dr. __________

LIST OF PHYSICIANS AND THEIR SPECIALTY

__Radiologist (X-rays and various scans): Dr.______________ __Rheumatologist (treat arthritis, diseases of the joints, connective tissues, muscles and bones): Dr.________________________________

__Surgeon (surgical procedures): Dr(s). _______ _______________________________________________

__Urologist (urinary system): Dr. _____________ __Dr(s)._______________________________________ _______________________________________________

ITEMIZED BILLING

In this journal you will have the ability to keep a complete record of physician visits, nursing visits, therapies, medications, and supplies you receive.

You need to understand that you will be billed for any visit from the doctor or their assistant. The fee will be charged as a physician visit even if it is from the assistant, resident, intern, or medical student that visited the patient and not the actual physician. The assistant talks with the physician about the condition of the patient and may not even actually visit or examine the patient but will sign the progress report or orders. Unfortunately some physicians will not see the patient at all but ask the nurse about the patient while filling out the progress notes and orders. The patient is still being charged for that visit since there are notes and orders as if they were actually seen by the physician. This is why there is a section about which physicians visited and if you were actually examined. You should compare this to your bill.

Look at the section of your bill that addresses various types of therapies. Physical and Occupational Therapy typically bill in unit time. A unit of time is usually a few minutes. A patient may be billed for therapy including range of motion exercises lasting a few minutes for the entire day or getting them in a chair and leaving them until the nursing staff puts the patient to bed. Look at how you are being billed for these services.

You should ask about medications you are receiving and record them if possible. Ask for a daily record of medications administered. Take a recording device and say what medications you are receiving and the times administered. Record the medications in your journal. Ask about the medications you are receiving. You will notice that occasionally the staff administering the medications have no idea why they are giving the medication to the patient due to the nurse having too many patients and not enough time to think about what is happening with each of the patients. This is usually the result of understaffing caused by corporate greed and the frustration of the nursing staff that filters down to the patient.

(Continues...)

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