Kingdom of Saudi Arabia

Ministry of Health
Directorate of Health Affairs - Najran
NAJRAN GENERAL HOSPITAL

INTERDISCIPLINARY PATIENT/ FAMILY EDUCATION FORM

NAME: _________________________________________________________________ FILE #: _____________________________
NATIONALITY: ________________________ AGE: __________ SEX: __________________ DEPARTMENT: _________________
Reason for Admission: _________________________________________________________________________________________
Section I. Detailed Patient Assessment to be Accomplised by Patient Educators/ Nurse within 48 hours of admission
Patients Initial Learning Assessment
Learner
Patient
Spouse
Father
Mother
Watcher
Reading Ability
Barriers to Learning
Communication Knowledge of
Motivation/
Family Assistance
Language
Disease is
Readiness to
Provided:
Able to read
None
learn
Arabic
Good
Often
Able to count
Cognitive
Motivated
Other
Limited
Sometime
Has difficulty
Sensory impairment
_____________
Not Motivated
None
Needed
Does not read
Cultural
_____________
Ready to learn
Comments
Does not apply
Comments
Religious belief
_____________
_____________
Delay teaching
________________ Language
Comments
_____________
_____________
________________ Comments
Comment
_______________
_____________
_______________ _______________
______________________ _____________

Are there any

cultural/ religious
practice that may
affect the patient
healthcare?
Yes
No
Comments
_______________

Name: ______________________________________________________ Code# ________________ Signature __________________ Date ______________

Section II. General Information Provided (to be completed by Patient Educator/ Nurse)
Received information about falls safety
Yes
No
Received written information about medical condition (e.g. leaflet)
Yes
No
Not Available
Other ____________________________________________________________________________________________________________________________
Name: ______________________________________________________ Code# ________________ Signature __________________ Date ______________
Section III. Patient Relation (to completed by Patient Relation Officer)
Received booklet on patients rights and responsibilities
Yes
No
Received information in watchers rules and regulations
Yes
No
Not Available
Other ____________________________________________________________________________________________________________________________
Date
Time
Notes
Code Number
Signature

Note: Please refer to assessment by Patient Educators (Section I)

Section IV. Detailed Patient Education
Patients Education Provided:
1. CONDITION (Physicians)
Referred to Patient Education on _______________ Referred to plan of care Other ____________________
Diagnosis Yes No
Procedure Yes No
Self-Management Yes No
Treatment Plan
Yes No
Date
Time
Teaching Provided
Code Number Signature
Patients Response

Patients Response to Teaching Session:

2.

1. Able to perform/ verbalize

2. Unable to perform/ verbalize
3. Needs reinforcement
4. Not receptive
PRE-/POST-OPERATIVE CARE (Nurses)
N/A
Ambulation
Dressing Changes
Other ______________________________
Date
Time
Teaching Provided
Code Number Signature
Patients Response

Patients Response to Teaching Session:

3.

1. Able to perform/ verbalize

2. Unable to perform/ verbalize
3. Needs reinforcement
4. Not receptive
MEDICATION (Nurses/ Pharmacists)
Purpose
Side Effects
Dosage
Other ______________________________
Referred to Pharmacist/ Clinical Pharmacist on ________________________________________
Date
Time
Teaching Provided
Code Number Signature
Patients Response

Patients Response to Teaching Session:

4.

1. Able to perform/ verbalize

NUTRITION (Nurses/ Dietitian)
Date

Time

2. Unable to perform/ verbalize

3. Needs reinforcement
4. Not receptive
Normal Diet
Referred to Clinical Nutrition Services on ________________
Modified Diet
Other ___________________________________________________________________
Teaching Provided
Code Number Signature
Patients Response

Patients Response to Teaching Session:

1. Able to perform/ verbalize

2. Unable to perform/ verbalize

Najran General Hospital | Patient and Family Education Form|

3. Needs reinforcement

4. Not receptive

PFE-001 Form A

Kingdom of Saudi Arabia

Ministry of Health
Directorate of Health Affairs - Najran
NAJRAN GENERAL HOSPITAL

INTERDISCIPLINARY PATIENT/ FAMILY EDUCATION FORM

NAME: _________________________________________________________________ FILE #: _____________________________
NATIONALITY: ________________________ AGE: __________ SEX: __________________ DEPARTMENT: _________________
5.

PAIN (Nurses/Physician) No pain

Date
Time

Pain Management Referred to Physician on _____________ Other _____________________

Teaching Provided
Code Number Signature
Patients Response

Patients Response to Teaching Session:

6.

1. Able to perform/ verbalize

2. Unable to perform/ verbalize
3. Needs reinforcement
4. Not receptive
ACTIVITY & REHABILITATION (Nurses/PT) Normal Activity Fall Prevention Referred to PT on _________ Other __________________
Date
Time
Teaching Provided
Code Number Signature
Patients Response

Patients Response to Teaching Session:

7.

1. Able to perform/ verbalize

2. Unable to perform/ verbalize
3. Needs reinforcement
4. Not receptive
MEDICAL EQUIPMENT
N/A
Equipment given __________________ Date _________________
Referred to ____________________
Other ________________________
Date
Time
Teaching Provided
Code Number Signature

Patients Response

Patients Response to Teaching Session:

8.

1. Able to perform/ verbalize

2. Unable to perform/ verbalize
3. Needs reinforcement
4. Not receptive
MISCELLANEOUS Abduction Awareness
Social Services
Breastfeeding
Other ___________________________________
Date
Time
Teaching Provided
Code Number Signature
Patients Response

Patients Response to Teaching Session:

1. Able to perform/ verbalize

2. Unable to perform/ verbalize

3. Needs reinforcement

4. Not receptive

Section V. Discharge Instruction

Follow up appointment
Emergency Care
Plan of Care
Discharge Medication
Purpose
Dosage
Storage
N/A
Other __________________________________________________________________________________________________________

Patients Response to Teaching Session:

1. Able to perform/ verbalize

2. Unable to perform/ verbalize

Najran General Hospital | Patient and Family Education Form|

3. Needs reinforcement

4. Not receptive

PFE-001 Form A