Patient Handbook

Patient Handbook
Private Medical Care
Patient Handbook
Tel: (877)741-9535
Fax: (877)742-0658
Private Medical Care
Tel: (877) 741-9535 Fax: (877) 742-0658
E-mail: [email protected]
Dear Client,
I am very pleased to welcome you to Privé Care. Here, you will recognize
the consistent hard work our skilled professionals have to offer.
Privé Care provides various services including nursing, care giver services,
physical therapy, speech therapy, occupational therapy, medical social services
and home health aide services to patients in their homes. We are a dedicated
medical concierge company whose vision is to provide clients with the best
medical assistance. For your satisfaction, we have a Registered Nurse available
on call 24 hours a day to better suit your needs.
Our professionals are people who enjoy helping clients in need without any
discrimination against race, color, religion, sex, creed, sexual preferences,
national origin, disability, or age in admission, treatment, staffing or participation in
its program, services and activities, or in employment.
Privé Care provides the compassion and comprehensive focus each client is
destined to receive. We keep in mind that our clients have the right to high quality
home health service by making sure each person is valued as an individual.
Rest assured our highly trained nursing personnel will be able to meet or exceed
all of your medical needs.
Maria Lozzano
Chief Operating Officer
THE FOLLOWING CONDITIONS MUST BE REPORTED TO THE ATTENDING PHYSICIAN ONCE THEY ARE IDENTIFIED: • TEMPERATURE OF >101 F • BLOOD PRESSURE SBP >160 OR <90, DBP>100 OR <60, UNLESS REPORTING PARAMETERS WERE ESTABLISHED BY ATTENDING PHYSICIAN. • BLOOD SUGAR <70 MG/DL OR >250 MG/DL UNLESS SPECIFIED BY ATTENDING PHYSICIAN • PULSE <60/MIN OR >120/MIN, FREQUENT PALPITATION • SIGNS AND SYMPTOMS OF HYPER/HYPOGLYCEMIA. • PRESENCE OF ADVENTITIOUS BREATH SOUNDS, CYANOSIS AND INCREASING SOB OR RESPIRATORY RATE OF <14/MIN OR >24/MIN • FAINTING EPISODES • SUDDEN CHANGES IN MENTAL STATUS/BEHAVIOR DECREASING LEVEL OF CONSCIOUSNESS • FALLS WITH OR WITHOUT INJURY • VISUAL CHANGES, SLURRED SPEECH, WEAKNESS AND NUMBNESS OF EXTREMITIES • CHEST PAIN NOT RELIEVED BY NTG OR REST • WOUND NOT RESPONDING TO PRESCRIBED TREATMEANT REGIMEN IN 4 WEEKS • BLEEDING FROM ANY ORIFICE/IMPENDING S/S OF SHOCK, CALL 911 • SIGNS AND SYMPTOMS OF DRUG, FOOD REACTION SUCH AS ITCHINESS, SOB, RASH, VOMITING, NUSEA, ETC • SIGNS AND SYMPTOMS OF DRUG TOXICITY AND SUB-­‐THERAPEUTIC LEVELS • ANY ABNORMAL LAB RESULTS • UNUSUAL INCIDENTS AND OCCURRENCES ANY FIELD STAFF IS RESPONSIBLE FOR NOTIFYING THE PMD/DPCS/CASE MANAGER PROMPTLY (WITHIN 24 HOURS OR SOONER) OF ANY SIGNIFICANT CHANGE IN THE PATIENT’S CONDITION OR TREATMENT PLAN (MD ORDERS, NEED FOR OTHER SERVICES, ETC.) CLIENT'S CONSENT/CERTIFICATION REQUEST FOR ADMISSION AND CONSENT TO TREATEMENT I consent to the initial evaluation by which the Agency will determine if I am eligible for admission to home care services. I request admission to the Agency and consent to such care and treatment as is ordered by me attending physician(s) through the Agency. I understand that my care is directed and monitored by me attending physician(s) and that the Agency is not liable for any act or omission when following the instruction of said physician(s), who are neither the employee nor the agent of the Agency. AUTHORIZATION TO RELEASE INFORMATION I consent to the release of information by any hospital, skilled nursing facility or home health agency in which I have been a patient, and authorize these health care professional to disclose all or any part of my medical record to the Agency. I authorize the Agency to give information about my health status to other health agencies and professional who are involved in my care, or to State, Federal and other accrediting agencies to review records, including the use of my medical chart for the purpose of Quality Improvement reviewed by the Agency. MEDICARE/SENIOR HMO Patient's certification. Authorization to release information and Payment request. I certify that the information given by me is applying for payment under the Title XVIII of the Social Security Act is correct. I authorize the release of all records required to act on this request. I request that payment of authorized benefits be made on my behalf. THE INDICATED SERVICES SHALL BE COVERED BY MEDICARE TO HOMEBOUND CLIENTS AT 100%. THE CLIENT SHALL NOT BE RESPONSIBLE FOR PAYMENT OF ANY SERVICES DISALLOWED BY MEDICARE. MEDICAL I accept the Agency's services as authorized by the Medi-­‐Cal Field Office. I understand these services shall be rendered upon receipt of a POE or Medi-­‐Sticker (or verification of my Medi-­‐Cal eligibility). THE INDICATED SERVICES SHALL BE COVERED AT 100% BY MEDICAL. PRIVATE INSURANCE AND SELF PAY I agree in consideration of the services I am to receive, I individually obligate myself to pay the account of the Agency in accordance with the regular rates and terms of Home Health Agency. Should the account be referred to an attorney for collection, I shall pay reasonable attorney's fees and collection expenses. All delinquent accounts bear interest at the legal rate. VISIT CHARGE RATES: SKILLED NURSING ____ ____$/VISIT SPEECH THERAPIST_________$/VISIT SOCIAL SERVICES ____ $/VISIT OCCUPATIONAL THERAPIST___________$/VISIT PHYSICAL THERAPIST _____ $/VISIT HOME HEALTH AIDE ____ $/VISIT THE SERVICES FOR PAYMENT OPTIONS HAVE BEEN EXPLAINED TO ME. I UNDERSTAND THE SERVICES I REQUIRE AND THE PAYMENT OPTION I HAVE CHOSEN. I HEARBY ACCEPT AND AGREE TO THE PROPOSED SERVICES AND PAYMENT OPTION. I HAVE RECEIVED A COPY OF THE AGENCY'S MEDICARE SERVICES CHARGES. The proposed services and frequency if approved by my doctor will be: Skilled Nursing______________________________ Physical Therapy___________________, Occupational Therapy___________________, Speech Therapy_____________________, Medical Social Worker___________________, Home Health Aide_____________________ ADVANCED DIRECTIVE INFORMATION Patient has a living will? No Yes (copy obtained ) Do not resuscitate If no copy obtained, list the contents of the living will:_____________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ I have a Durable Power of Attorney for Health Care Name:______________________________________________ Phone Number___________________________, Address_____________________________________________________________________ Patient's Initials: _____________ CLIENT'S CONSENT/CERTIFICATION COMPLAINT PROCEDURE If you have a complaint or question of an ethical nature or if you feel your rights have been denied, you can contact the Clinical Supervisor at (323) 932-­‐0773. If unresolved at this level, you should then contact the Director of Patient Care Services/Administrator at which time you may be instructed to put your complaint in writing. A decision by the Director of Patient Care Services/Administrator is binding and final. Each level must respond within 5 (five) working days. No reprisal will result from the complaint. In addition or instead of voicing your complain to the Agency, you can call the California Department of Public Health, Licensing and Certification Division from 8:00 am to 5:00 pm Monday through Friday at the toll free number for Los Angeles County at (800)228-­‐1019 or write to County of Los Angeles, Department of Health Services, Public Health Programs at 600 So. Commonwealth Ave., Ste 903, Los Angeles, CA 90005. Voice messages may be left 24 hours a day. You will not be subject to any reprisals or discrimination from the agency. You can call before, during, or after you have discussed the complaint with the agency. You may also contact Joint Commission if you have any concerns about safety or your care, treatment and services at (800)994-­‐6610, 24 hours a day, 7 days a week. Staff members are available to answer calls only on weekdays between 8:30 am and 5:00 pm Central Standard time. You may also email Joint commission at [email protected] CERTIFICATION My signature attests to the fact that I have been given the following: 1. I certify that I have received a copy of and have been educated on the "Patient's Bill of Rights and Responsibilities" 2. I have been informed on how to file a complaint if need be and have received a copy of "information about the Agency" 3. My initial Plan of Treatment has been discussed with me and I also have been actively involved in planning my care with Prohealth Home Care Services, Inc. 4. I have been informed about the Home Health Hotline and how to use it if necessary. 5. I certify that I have been advised regarding an Emergency Plan for my care and have received written and verbal instructions in safety related to my care. 6. I have received a copy of the Advanced Directive information. 7. I have received a copy of this document. 8. I have received notice of Privacy Practices. Patient's Name_______________________________________________________________________________ MR #_______________________ Patient's Signature____________________________________________________________________________ Date:_____________________ Signature of Patient Representative if Patient is unable to sign ____________________________Date:____________________ If patient did not sign, please state the reason _________________________________________________________________________ Witness____________________________________________________________________Date:__________________________________________ Translator's Signature __________________________________________________________________________Date:___________________ PRIVACY ACT STATEMENT -­‐ HEALTH CARE RECORDS THIS STATEMENT GIVES YOU ADVICE REQUIRED BY LAW (the Privacy Act of 1974). THIS STATEMENT IS NOT A CONSENT FORM. IT WILL NOT BE USED TO RELEASE OR TO USE YOUR HEALTH CARE INFORMATION. I. AUTHORITY FOR COLLECTION OF YOUR INFORMATION, INCLUDING YOUR SOCIAL SECURITY NUMBER, AND WHETHER OR NOT YOU ARE REQUIRED TO PROVIDE INFORMATION FOR THIS ASSESSMENT. Sections 1102(a), 1154, 1861(o), 1861(z), 1863, 1864, 1865, 1866, 1871, 1891(b) of the Social Security Act. Medicare and Medicaid participating home health agencies must do a complete assessment that accurately reflects your current health and includes information that can be used to show your progress toward your health goals. The home health agency must use the ^Outcome and Assessment Information Set] (OASIS) assessment, it is protected under the federal Privacy Act of 1974 and the ^Home Health Agency Outcome and Assessment Information Set] (HHA OASIS) System of Records. You have the right to see, copy, review, and request correction of your information in the HHA OASIS System of Records. II. PRINCIPAL PURPOSES FOR WHICH YOUR INFORMATION IS INTENDED TO BE USED The information collected will be entered into the Home Health Agency Outcome and Assessment Information Set (HHA OASIS) System No. 09-­‐70-­‐9002. Your health care information in the HHA OASIS System of Records will be used for the following purposes: A support litigation involving the Centers for Medicare & Medicaid Services; A support regulatory, reimbursement, and policy functions performed within the Centers for Medicare & Medicaid Services or by a contractor or consultant; A study the effectiveness and quality of care provided by those home health agencies; A survey and certification of Medicare and Medicaid home health agencies; A provide for development, validation, and refinement of a Medicare prospective payment system; A enable regulators to provide home health agencies with data for their internal quality improvement activities; A support research, evaluation, or epidemiological projects related to the prevention of disease or disability, or the restoration or maintenance of health, and for health care payment related projects; and A support constituent requests made to a Congressional representative. III. ROUTINE USES These ^routine uses] specify the circumstances when the Centers for Medicare & Medicaid Services may release your information from the HHA OASIS System of Records without your consent. Each prospective recipient must agree in writing to ensure the continuing confidentiality and security of your information. Disclosures of the information may be to: 2. contractors or consultants working for the Centers for Medicare & Medicaid Services to assist in the performance of a service related to this system of records and who need to access these records to perform the activity; 3. an agency of a State government for purposes of determining, evaluating, and/or assessing cost, effectiveness, and/or quality of health care services provided in the State; for developing and operating Medicaid reimbursement systems; or for the administration of Federal/State home health agency programs within the State; 4. another Federal or State agency to contribute to the accuracy of the Centers for Medicare & Medicaid Services' health insurance operations (payment, treatment and coverage) and/or to support State agencies in the evaluations and monitoring of care provided by HHAs; 6. an individual or organization for a research, evaluation, or epidemiological project related to the prevention of disease or disability, the restoration or maintenance of health, or payment related projects; 7. a congressional office in response to a constituent inquiry made at the written request of the constituent about whom the record is maintained. IV. EFFECT ON YOU, IF YOU DO NOT PROVIDE INFORMATION The home health agency needs the information contained in the Outcome and Assessment Information Set in order to give you quality care. It is important that the information be correct. Incorrect information could result in payment errors. Incorrect information also could make it hard to be sure that the agency is giving you quality services. If you choose not to provide information, there is no federal requirement for the home health agency to refuse you services. NOTE: This statement may be included in the admission packet for all new home health agency admissions. Home health agencies may request you or your representative to sign this statement to document that this statement was given to you. Your signature is NOT required. If you or your representative sign the statement, the signature merely indicates that you received this statement. You or your representative must be supplied with a copy of this statement. CONTACT INFORMATION that the Federal agency maintains in its HHA OASIS System of Records: Call 1-­‐800-­‐MEDICARE, toll free, for assistance in contacting the HHA OASIS System Manager. TTY for the hearing and speech impaired: 1-­‐877-­‐486-­‐
2048. care to its patients. You have the right to refuse to provide information for the assessment to the home health agency. If your information is included in and when evaluating your health. To do this, the agency must get information from every patient. This information is used by the Centers for Medicare & Medicaid Services (CMS, the federal Medicare & Medicaid agency) to be sure that the home health agency meets quality standards and gives appropriate health Improvement Organizations, to perform Title XI or Title XVIII functions relating to assessing and improving home health agency quality of care; 5. quality Q 1. the federal Department of Justice for litigation involving the Centers for Medicare & Medicaid Services; If you want to ask the Centers for Medicare & Medicaid Services to see, review, copy, or correct your personal health information NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. USE AND DISCLOSURE OF HEALTH INFORMATION Privé Care, may use your health information, information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provision of the Health Insurance Portability and Accountability Act of 1996, for purposes of providing you treatment, obtaining payment for your care and conducting health care operations. The Agency has established policies to guard against unnecessary disclosure of your health information.
THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED: To Provide Treatment: The Agency may use your health information to coordinate care within the Agency and with others involved in your care, such as your attending physician and other health care professional who have agreed to assist the Agency in coordinating care. For example, physicians involved in your care will need information about your symptoms in order to prescribe appropriate medications. The Agency also may disclose your health information to individuals outside of the Agency involved in your care including family members, pharmacists, and suppliers of medical equipment or other health professionals. To Obtain Payment: The Agency may include your health information in invoices to collect payment from third parties for the care you receive from the Agency. For example, the Agency may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse the Agency. To Conduct Health Care Operations: the Agency may use and disclose health information for its own operations in order to facilitate the function of the Agency and as necessary to provide quality care to all of the Agency's patients. Health care operations includes such activities as: Quality assessment/management; Professional Review and performance evaluations; Business management/Administrative activities of the Agency; Accreditation/Certification/Licensing or Credentialing activities; Reviews and auditing, including compliance reviews, medical reviews, legal services and compliance programs; Policy & Procedure development, case management and care coordination. For Fundraising Activities: The Agency may use information about you including your name, address, phone number and the dates you received care in order to contact you to raise money for the Agency. The Agency may also release this information to a related Agency Foundation. If you do not wish the Agency to contact you, notify the agency Administrator, at 323-­‐932-­‐0773 and indicate that you do not wish to be contacted. For Appointment Reminders: the Agency may use and disclose your health information to contact you as a reminder that you have an appointment for a home visit. For Treatment Alternatives: the Agency may use and disclose your health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you. THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTATNCES UNDER WHICH AND PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY ASLO BE USED AND IS REQUIRED TO BE DISCLOSED: When Legally Required: The Agency will disclose your health information when it is required by any Federal, State or local law. When There Are Risks to Public Health: The Agency may disclose you health information for public activities and purposes in order to prevent or control communicable diseases, notify a person who has been exposed to a communicable disease or who may be at risk for contracting or spreading a disease; report adverse effects, product defects to track products or enable product recalls, repairs and replacements and to conduct post-­‐marketing surveillance and compliance with requirements of the Food and Drug Administration. To Report Abuse, Neglect or Domestic Violence: the Agency is required to notify government authorities if the Agency believes a client is the victim of abuse, neglect or domestic violence. To Conduct Health Oversight Activities: The Agency may disclose your health information to a health oversight agency for activities including audits, civil administration or criminal investigations, inspections, licensure or disciplinary action. The Agency, however, may not disclose your health information if you are the subject of an investigation and your health information are not directly related to your receipt of health care or public benefits. In Connection With Judicial and Administrative Proceedings: the Agency may disclose your health information in the course of any judicial or administrative proceeding in response to an order of the court or administrative tribunal as expressly authorized by such order or in response to a subpoena, discovery request or other lawful process, but only when the Agency makes reasonable efforts to either notify you about the request or to obtain an order protecting your health information. For Law Enforcement Purposes: as permitted or required by State law, the Agency may disclose your health information to a law enforcement official for certain law enforcement purposes as follows: as required by law for reporting of certain types of wounds or other physical injuries pursuant to the court order, warrant, subpoena or summons or similar process; for the purpose of identifying or locating a suspect, fugitive, material witness or missing person; in an emergency in order to report a crime. To Coroners and Medical examiners: the Agency may disclose information to coroners and medical examiners for purposes of determining your cause of death or for other duties, as authorized by law. To Funeral Directors: the Agency may disclose your health information to funeral directors consistent with applicable law and if necessary, to carry out their duties with respect to your funeral arrangements. If necessary to carry out their duties, the Agency may disclose your health information prior to and in reasonable anticipation of your death. For Organ, Eye or Tissue Donation: the Agency may use or disclose your health information to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs, eyes or tissue for the purpose of facilitating the donation and transplantation. For Research Purposes: the Agency may under very select circumstances, use your health information for research. Before the Agency discloses any of your health information for such research purposes, the project will be subject to an extensive approval process. In the Event of A Serious Threat To Health Of Safety: the Agency may, consistent with applicable law and ethical standards of conduct, disclose your health information if the Agency, in good faith, believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public. For Specified Government Functions: in certain circumstances, the Federal regulations authorize the Agency to use or disclose your health information to facilitate specified government functions relating to military and veterans, national security and intelligence activities, protective services for the President and other, medical suitability determinations and inmates in law enforcement custody. For Worker's Compensation: the Agency may release your health information for worker's compensation or similar programs. AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION Other than is stated above, the Agency will not disclose your health information other than with your written authorization. If you or your representative authorizes the Agency to use or disclose your health information, you may revoke that authorization in writing at any time. YOU’RE RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION You have the following rights regarding your health information that the Agency maintains: • Right to request restrictions: you may request restrictions on certain uses and disclosures of your health information. You have the right to request a limit on the Agency's disclosure of your health information to someone who is involved in your care or the payment of your care. However, the Agency is not required to agree to your request. • Right to receive confidential communications: you have the right to request that the Agency communicate with you in a certain way. For example, you may ask that the Agency only conduct communications pertaining to your health information with you privately with no other family members present. We will make every attempt to honor your request. • Right to inspect and copy your health information: you have the right to inspect and copy your health information, including billing records. A request to inspect and copy records containing your health information must be made in writing. The Agency may charge a reasonable fee for copying and assembling costs associated with your request. • Right to Amend Health Care Information: you or your representative have the right to request that the Agency amend your records, if you believe that your health information is in correct or incomplete That request may be made in writing as long as the information is maintained by the Agency. The Agency may deny your request, and if so, you may submit a statement of disagreement. However, we will make every attempt to honor your request. • Right to an Accounting: you or your representative have the right to request an accounting of disclosures of your health information made by the Agency for purposes other than treatment, payment and health care operations. We will make every attempt to honor your request. The request should specify the time period for the accounting starting on or after 02/15/2011. Accounting requests may not be made for periods of time in excess of six (6) years. The Agency would provide the first accounting you request during any 12-­‐months period without charge. Subsequent accounting requests may be subject to a reasonable cost-­‐
based fee. • Right to a paper copy of this Notice: you or your representative have a right to a separate paper copy of this Notice an any time even if you or your representative have received this Notice previously. TO EXERCISE ANY OF THE ABOVE RIGHTS PLEASE WRITE TO THE ADMINISTRATOR OR DIRECTOR OF THE PATIENT CARE SERVICES: Privé Care, 19500 Normandie Ave, Torrance, CA 90502
If you have any questions please contact us at 877-­‐741-­‐9535 OUR DUTIES IN PROTECTING YOUR HEALTH INFORMATION The Agency is required by law to maintain the privacy of your health information and to provide to you and your representative this Notice of its duties and privacy practices. The Agency is required to abide by the terms of this Notice as may be amended from time to time. The Agency reserves the right to change the terms of its Notice and to make the new notice provisions effective for all health information that it maintains. If the Agency changes its Notice, the Agency will provide a copy of the revised Notice to you or your appointed representative. You or your representative has the right to express complains to the Agency and to the Secretary of DHHS if you or your representative believe that your privacy rights have been violated. Any complaints to the Agency should be made in writing Privé Care, 19500 Normandie Ave, Torrance, CA 90502. The Agency encourages you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint.
CONTACT PERSON: The Agency has designated the Privacy Official as its contact person for all issues regarding client privacy and your rights under the Federal privacy standards. IF YOU HAVE ANY QUESTION REGARDING THIS NOTICE, PLEASE CONTACTT THE PRIVACY OFFICIAL AT Privé Care, 19500 Normandie Ave, Torrance, CA 90502 OR CALL 877-­‐741-­‐9535
EFFECTIVE DATE: This Notice is effective 11/15/2014 This book contains information regarding:
Home Care Services
Your Rights and Responsibilities
Your Right to Make Decisions about Medical Treatment
Helpful information:
o Medication Tips
o Infection Control in the Home
o Equipment Safety Tips
o Safety in Your Home
o Earthquake Safety Tips
o What To Do In a Disaster
o Area Resources
o Emergency Phone Numbers
o Drug Classification
o Food and Drug Interaction Guide
Description of Services
Dear Patient,
Our agency provides nursing, physical therapy, speech therapy, occupational therapy, social services and home health
aide services to patients in their homes. These services can only be provided through your doctor’s orders and are paid
for by your insurance carrier as long as you meet the appropriate eligibility guidelines. A brief description of these
guidelines is as follows: (Please note, these guidelines do not guarantee payment for services, and for detailed
information you should review your individual policy):
Medicare will only pay for services as long as: 1) you are homebound,
(That means that it must take a taxing and considerable effort on your
Part to leave your home) 2) skilled services are medically necessary
On an intermittent or part-time basis; 3) you remain under a
Physician’s care while receiving services.
Medi-Cal and IMS will pay for limited services if: 1) hands-on skilled
Care is provided; 2) you are homebound; 3) the care is medically
Private Insurance
Eligibility guidelines depend on the carrier and an individual’s policy. Pre-authorization is usually
required and is completed by our office staff.
It is our goal to assist you back to recovery and a normal independent way of life as soon as possible. As you recover, the
services of our staff will decrease.
Before you accept our services, you must receive a copy of two forms, “Patient’s Bill of Rights and Responsibilities” and
“Your Right to Make Decisions about Medical Treatment”, and be informed of our agency’s policy regarding
resuscitation. This means that if necessary, our staff will provide CPR or contact 911 unless instructed otherwise by you.
If you do not want our staff to perform resuscitation measures, you must contact your physician, obtain an order, and
complete a legal document known as an Advanced Directive. This may be in the form of a Durable Power of Attorney
for Health Care, A Declaration Pursuant to the Natural Death Act, a living will, or a Do Not Resuscitate Directive.
Please be advised that if Home Health Aide services are provided, they are to assist you with your personal needs related
to your medical condition. Please do not ask them to perform the following tasks:
Change linens, prepare meals, grocery shop, or wash dishes for ANYONE OTHER THAN YOU, THE
Move furniture, wash windows, walls, floors or any heavy housekeeping chores
Drive anyone in their car or drive another car for the patient
These tasks are allowable for patients only: dusting, vacuuming, sweeping, damp mopping, dishes, laundry, linens, and
cleaning the bathroom.
We hope these suggestions will aid you in understanding our services. You may contact our office from 8 am to 5 pm,
Monday – Friday. After hours, Saturdays and Sundays, and on holidays leave your message with our answering service.
The Registered Nurse On-Call will get back to you as soon as possible.
Thank you for choosing our agency. We hope you will find our service satisfactory, and wish you a speedy recovery.
You have received a copy of the Patient Rights and Responsibilities document in addition to several other
forms/handouts. Organization personnel reviewed these materials with you on the initial visit. In
addition, there are other organization policies and procedures reviewed with you that are related to your
rights as a patient receiving service from this organization. These policies and procedures are
summarized below:
You were asked during the initial visit if you had executed an Advance Directive. If you have not
executed an Advance Directive, you have also been provided with literature relative to your rights under
federal and state law to execute such a document.
Organization policy states that:
“The organization recognizes that all persons have a fundamental right to make decisions
relating to their own medical treatment, including the right to accept or refuse medical care.
It is the policy of the organization to encourage individuals and their families to participate in
decisions regarding care and treatment. Valid Advance Directives, such as living wills,
Durable Powers of Attorney, and DNR (Do Not Resuscitate) or DNI (Do Not Incubate)
Orders will be followed to the extent permitted and required by law. In the absence of
Advance Directives, the organization will provide appropriate care according to the plan of
treatment authorized by the attending physician. The organization will not condition the
provision of care or otherwise discriminate against an individual based on whether or not the
individual has executed an Advance Directive.”
It is also the organization's policy that:
“In the event of cardiac or pulmonary arrest, cardiopulmonary resuscitative measures will be
promptly initiated unless a Do Not Resuscitate/Do Not Incubate (DNR/DNI) order has been written
by the physician (or other authorized licensed independent practitioner) in charge and documented
in the patient's clinical record.”
1. A DNR and/or DNI decision is to be made by the attending physician in consultation
with the patient or other legally responsible person when, in the judgment of the
physician, the patient suffers from an incurable terminal illness, death is reasonably
imminent in all medical probability, and resuscitation will do nothing to relieve the
underlying disease condition, nor the probability of death. This order must be written
in the patient's clinical record as any other treatment order.
2. The DNR/DNI order will be re-evaluated under the following conditions:
A. There is a significant change in patient condition
B. At the request of the patient or his/her legally responsible person
GUIDELINES (continued)
3. It will be the responsibility of the nurse to communicate to the primary attending
physician any change in the patient's condition that may make a continuing DNR/DNI
order questionable, so that the physician (or other authorized licensed independent
practitioner) may re-evaluate the appropriateness of the order.
4. The order may be revoked at any time, verbally or in writing, by the competent patient,
the incompetent patient's guardian, or by the attending physician (or other authorized
licensed independent practitioner).
5. The DNR/DNI order(s) will be kept in the patient’s clinical record, and a copy will be
kept in the patient’s home.
6. Any organization personnel informed of or provided with a revocation of consent will
immediately record the revocation request in the patient's clinical record, cancel the
order, and notify the physician (or other authorized licensed independent practitioner)
responsible for the patient's care of the revocation and cancellation.
It is also this organization's policy that if an organization staff member informs management that he/she
cannot implement an Advance Directive or DNR/DNI order on the basis of personal belief or conscience,
then that organization staff member will be reassigned.
As a consequence of the complex technical and ethical issues arising today in the provision of care at
home, the organization has ethics advisors. These advisors assist the organization in responding to the
challenges confronting health care providers who are involved in difficult treatment choices and care
decisions. Care decisions may involve ethical issues regarding the withholding or withdrawal of
treatment. You, or your representative, have the right to participate in any discussions concerning ethical
issues arising from your care.
If you have any questions concerning your rights, these related policies, or other organization polices,
please discuss them with your nurse or call the office and ask to speak with the Clinical Supervisor.
This section explains your rights to make health care decisions
and how you can plan what should be done when you can’t
speak for yourself.
A federal law requires us to give you this information. We
hope this information will help increase your control over your
medical treatment.
Your doctor will give you information and advice about
treatment. You have the right to choose. You can say “Yes” to
treatments you want. You can say “No” to any treatment you
don’t want- even if the treatment might keep you alive longer.
Your doctor must tell you about your medical condition and
about what different treatments can do for you. Many
treatments have “side effects.” Your doctor must offer you
information about serious problems that medical treatment is
likely to cause you.
Often, more than one treatment might help you- and people have different ideas about
which is best. Your doctor can tell you which treatment is available to you, but your
doctor can’t choose for you. That choice depends on what is important to you.
If you can’s make treatment decisions, your doctor will ask
your closest available relative or friend to help decide what is
best for you. Most of the time that works. But sometime
everyone doesn’t agree about what to do.
After to choose someone, talk to that person about what you
want. You can also write down in the Durable Power of
Attorney For Health Care when you would or wouldn’t want
the medical treatment. Talk to your doctor about what you
want and give your doctor a copy of the form. Give another
copy to the person named as your agent, and take a copy with
you when you go into a hospital or other treatment facility.
Sometimes treatment decisions are hard to make and it truly
helps your family and your doctors if they know what you
want. The Durable Power of Attorney For Health Care also
gives them legal protection when they follow your wishes.
You can use another kind of advance directive to write down
your wishes about treatment. This is often called a “living
will” because it takes effect while you are still alive, but have
become unable to speak for yourself.
The California Natural Death Act lets you sign a living will
called a Declaration. Anyone 18 years or older and of sound
mind can sign one.
When you sign a Declaration it tells your doctors that you
don’t want any treatment that would only prolong your dying.
All life-sustaining treatment would be stopped if you were
That’s why it is helpful if you say in advance what you want to
happen if you can’t speak for yourself. There are several kinds
of “advance directives” that you can use to say what you want
and who you want to speak for you.
One kind of advance directives under California law lets you
name someone to make health care decisions when you can’t.
This form is called a Durable Power of Attorney for Health
If you can’s make treatment decisions, your doctor will ask
your closest available relative or friend to help decide what is
best for you. Most of the time that works. But sometime
everyone doesn’t agree about what to do.
That’s why it is helpful if you say in advance what you want to
happen if you can’t speak for yourself. There are several kinds
of “advance directives” that you can use to say what you want
and who you want to speak for you.
One kind of advance directives under California law lets you
name someone to make health care decisions when you can’t.
This form is called a Durable Power of Attorney for Health
You can, if you are 18 years or older and of sound mind. You
do not need a lawyer to fill out.
You can choose an adult relative or friend you trust as your
“agent” to speak for you when you’re too sick to make your
own decisions.
Instead of using the Declaration in the Natural Death Act, you
can use any of the available living will forms. You can use a
Durable Power of Attorney For Health Care form without
naming an agent, or you can just write down your wishes on a
piece of paper. You doctors and family can use what you write
in deciding about your treatment, but living wills that don’t
meet the requirements of the Natural Death Act don’t give as
much legal protection for your doctors if a disagreement arises
about following your wishes.
You can change or revoke any of these documents at any time
as long as you can communicate your wishes.
No, you don’t have to fill out any of these forms if you don’t
want to. You can just talk with your doctors and ask them to
write down what you’ve said in your medical chart. And you
can talk with your family, but people will be clearer about your
treatment wishes if you write them down. Your wishes are
more likely to be followed if you write them down.
Absolutely. You will still get medical treatment. We just want
you to know that if you become too sick to make decisions,
someone else will have to make them for you. Remember that:
terminally ill and your death was expected soon, or if you were
permanently unconscious. You would receive treatment to
keep you comfortable, however.
The doctors must follow your wishes about limiting treatment
or turn your care over to another doctor who will. Your doctors
are also legally protected when they follow your wishes.
If you don’t have someone you want to name to make
decisions when you can’t, you can sign a Natural Death
Act Declaration. This Declaration says that you do not
want life prolonging treatment if you are terminally ill or
permanently unconscious.
Ask your doctor, nurse or social worker to get more
information for you.
A Durable Power of Attorney for Health Care lets you
name someone to make treatment decisions for you. That
person can make most medical decisions-not just those
about life-sustaining treatment-when you can’t speak for
yourself. Besides naming an agent, you can also use the
form to say when you would and wouldn’t want particular
kinds of treatment.
It is your responsibility to provide a copy of your advance
directive to the agency so that it can be kept with your records.
If you have any questions about any of these forms, please talk
to your doctor, your nurse, or call our office. Ask for a social
worker to visit you and further explain these directives.
The California Consortium on Patient Self-Determination
prepared the preceding text, which has been adopted by the
California Department of Health Services to implement Public
Law 101-508.
All of us at our agency want our patients to understand their
rights to make medical treatment decisions. We comply with
California laws and court decisions on advance directives. We
do not condition the provision of care or otherwise
discriminate against anyone based on whether or not you have
executed an advance directive. We have formal policies to
ensure that your wishes about treatment will be followed.
Information Regarding Your Medication Regimen
Your doctor has prescribed medication to help you treat your
condition. This medication will help you only if you take it
correctly. Here’s how:
Have your prescription filled at the pharmacy you ordinarily
use. That way, the pharmacist can keep a complete record of
your medications. Tell him if you are allergic to any
If you need to refill your prescription, don’t wait until the last
minute. Refill it before you run out of medication. There
should be no disruption in your dosing regime.
Take your medication in a well lit room. Double check the
label to make sure you is taking the right medication at the
right time. If you don’t understand the directions, call your
pharmacist or doctor.
If you forget to take a dose or several doses, don’t take two or
more doses together. Instead, contact your doctor or
pharmacist for directions.
Don’t stop taking your medication unless your doctor tells you
to. Do not self-prescribe or self-regulate.
Make sure you shake the liquid medicine bottles effectively
before taking.
Keep your medication in its original container or in a properly
labeled prescription bottle. If you are taking more than one
medication, don’t store them together in a pill box or container.
Store your medication in a cool, dry place or as directed by
your pharmacist. Don’t keep in the bathroom medicine cabinet
where heat and humidity may cause it to lose its effectiveness.
Some medications require refrigeration. Please read labels
If you have children, make sure your medication containers
have childproof caps. Always keep the containers beyond the
reach of children.
Wash your hands before taking your medications to avoid
At Home Infection Control
Infections can be a major health hazard. An infection is a
disease that results when germs invade and grow in the body.
Some infections can cause a short illness while others can be
very serious. The infections may involve a body part or the
whole body. Patients and caregivers need to protect themselves
from infections. You can help prevent infections by practicing
the following guidelines:
Hand washing is the one most important procedure
to prevent the spread of infection.
a. Wash your hands before and after
providing care
b. Wash your hands before preparing food
c. Wash your hands before eating
d. Wash your hands after using the bathroom
e. Use liquid soap in the bathroom
Each family member should use his or her own
towels, washcloths, toothbrush, drinking glass, and
other personal care items
Wash cooking and eating utensils with hot soapy
water after they have been used.
Clean cooking and eating surfaces with soap and
water of a disinfectant.
Do not leave food sitting out and uncovered. Close
all food containers. Refrigerate foods that will spoil.
Keep hot food hot and cold food cold.
Soiled bed linens should be changed immediately.
Soiled linens should be washed in hot water using a
detergent. Wash separately from other laundry.
Soiled disposable products (dressings, diapers)
should be placed in a heavy plastic bag, fastened
securely and placed in the trash pick-up.
Used needles and syringes can be placed into rigid
walled containers (empty bleach bottle), sealed
securely and disposed of in the trash for trash pickup.
Damp mop uncarpeted floors at least once a week.
10. Bathroom surfaces: sink, toilet, toilet seat and floor
should be cleaned routinely. A disinfectant,
bathroom cleaner or a solution of water and
detergent is used.
11. Special precautions to prevent infection in your
particular condition will be discussed, as necessary,
by the nurse at your home visits.
12. Notify the nurse or physician if the patient develops
any of the following signs or symptoms: fever, pain
or tenderness, fatigue, loss of appetite, nausea,
vomiting, diarrhea, and rashes, sore on mucous
membranes, redness or swelling of a body part, and
discharge or drainage from any area of the body.
13. Clean up spills of blood or urine with a 10% bleach
solution (mix 1 part of bleach to 10 parts of water
daily). Throw away unused bleach solution at the
end of the day.
14. Whenever possible, the family should wear
disposable gloves when in contact with the patient’s
blood, would drainage, feces, urine, open areas of the
skin, or other bodily fluids.
15. Clean utility gloves with hot soapy water; then
disinfect the gloves with a 10% solution of bleach.
Throw away and replace cracked gloves.
16. Cover your mouth and nose when coughing or
sneezing to prevent the spread of germs. Turn your
head to avoid droplets from coughs or sneezes.
Hospital Bed
Always keep wheels locked. Unlock only to move
When ready to ambulate stand a few minutes with
the walker to steady your balance.
Always maintain side rails up and locked into
Walking surface should be dry, clean and well
lighted. Removing throw rugs will enhance safety.
Electric beds may malfunction or a power failure
may cause the bed to remain in one position. Always
know how to use the manual hand crank
When walking do not look at your feet-look straight
A bedridden person should always have a way to
summon help. Provide patient with a call bell or
other emergency response system.
Wear supportive, flat soled, non-skid shoes. Avoid
high heels and slip-on shoes.
Attach a light weight bag or basket to your walker to
safely carry small items.
Unplug electric beds before washing the mattress or
Always lack the wheelchair brakes before making
transfers to or from your chair or bed or car.
If you are unable to place both feet flat on the floor
do not lean forward in the wheelchair-you may fall.
Prolonged sitting in the wheelchair may cause
pressure sores to develop. Establish a routine of
shifting your weight from side to side, up and down,
if possible. The armrest of the wheelchair may be
padded to help cushion and relieve pressure to arms.
Canes and Crutches
Avoid walking on slippery, wet or uneven surfaces.
Removing throw rugs will enhance safety.
Make sure the rubber tip on the cane/crutch end is
without cracks or tears and that it fits securely.
Crutches should have padded underarm rests.
Always look straight ahead while walking with a
cane, do not look at your feet.
Always get up slowly from a sitting position and assess if you
feel dizzy or off balance. While standing breathe slowly. If
dizziness should persist, sit down and call for assistance.
Patient Education: Fall Prevention Program In order to prevent falls and injuries at home, we have listed you some important precautions/ measures to follow: •
Do not attempt to climb up/down stairs without assistance and/or without holding onto rails. •
If you have poor vision, please make sure you have adequate light in your home. Do not attempt to walk in the dark. •
Put in a night-­‐light so you can see where you’re walking. Some night-­‐
lights go on by themselves after dark. •
If you are taking Hypnotics or sleeping pills and feel drowsy, do not attempt to do any activities unassisted. •
Remove the rugs or use double-­‐
sided tape or a non-­‐slip backing so the rugs won’t slip. •
Always keep objects off the floor and have a clear pathway in every room/hallway throughout your home. •
Put a non-­‐slip rubber mat or self-­‐
stick strips on the floor of the tub or shower. •
Exercise regularly. Exercise makes you stronger and improves your balance and coordination. •
Keep emergency numbers in large print near each phone. •
Put a phone near the floor in case you fall and can’t get up. •
Think about wearing an alarm device that will bring help in case you fall and can’t get up. Prevent falls with these simple fall-­‐prevention measures, from reviewing your medications to hazard-­‐proofing your home. Oxygen Therapy
Keep an all purpose fire extinguisher in your home
Electric blankets and electric heating pads may be a
potential hazard
Use only water-soluble lubricating jelly if needed.
Do not use products that contain oil or alcohol, as
they flammable.
Clean your cannula or mask every eight hours with a
wet cloth.
Oxygen tubing should not be covered by bed linen,
clothing or furniture.
Oxygen tank systems should be kept upright and
always turned off when not in use.
Oxygen containers should never be put in the truck
of the car.
Equipment may be wiped clean with household
detergent and warm water.
Tips for staying independent
Falls or other injuries could leave you unable to live on your
own. It is our hope that the following information will enable
you to make your home safer and more comfortable.
Removing potential hazards and making things easier to do can
help you stay independent.
Having an emergency plan
Listed on the back page of this booklet you will find local
emergency numbers. If numbers for your particular area are
not listed, space is provided for you to include those numbers.
Remember Race:
R= REMOVE patient and family from immediate danger.
Develop a fire escape plan for your home and determine one
place for all family members to meet outside in a safe place
away from the fire.
A= ACTIVATE – call 911. Remember to give your street
C= CONTAIN the fire, if possible, by closing all doors.
Remember your own safety first and do not place yourself in
E= EXTINGUISH the fire if possible, if not, evacuate the
area. Again, do not place yourself in any danger.
Fire Safety
Do you have an emergency exit plan?
Once a fire starts, it spreads rapidly. Since you may not have
much time to get out and there may be a lot of confusion, it is
important that everyone knows what to do.
Check smoke detectors
Do you have smoke detectors installed in your
If the answer is no, we urge you to purchase smoke detectors
for your own personal safety. Not: Some local fire departments
or local government agencies will provide assistance in
acquiring or installing smoke detectors.
Many home fire injuries and deaths are caused by smoke and
toxic gases, rather than the fire itself. Smoke detectors provide
an early warning and can wake you in the event of a fire.
You may want to consider Carbon Monoxide detectors for
your home safety.
At least one smoke detector should be placed near bedrooms,
either on the ceilings or 6-12 inches below the ceiling on the
wall. Place smoke detectors away from air vents.
Are your smoke detectors currently in proper working
Check the batteries on a regular basis.
Getting rid of hazards
Check areas around beds
Hazards that can cause fires, falls and other injuries in the
home are easy to overlook.
At the time, they’re often easy to fix.
Checking each room for safety hazards can help you prevent
Are lamps or light switches within easy reach of the bed?
Lamps located close to each bed will enable people getting up
at night to see where they are going. Rearrange furniture closer
to switches or move lamps close to beds. Install night lights
Check all rugs, runners and mats
Are all small rugs and runners slip-resistant?
Estimates that in 1982, over 2,500 people age 65 and over
were treated in hospital emergency rooms for injuries that
resulted from tripping over rugs and runners. Falls are also the
most common cause of fatal injury to older people.
Remove rugs and runners that tend to slide.
Apply double-faced adhesive carpet tape or rubber
matting to the backs of rug and runners.
Purchase rugs with slip-resistant backing
Check rugs and mats periodically to see if the
backing needs to be replaced.
Place rubber matting under rugs. Rubber matting can
be cut to the size of the rug.
Note: Over time adhesive on tape can wear away. Rugs with
slip-resistant backing also become less effective as they are
washed. Periodically check rugs and mats to see if new tape or
backing is needed.
Check bathtub and shower areas
Are bathtubs and showers equipped with non-skid mats,
abrasive strips or surfaces that are not slippery?
Wet, soapy tile or porcelain surfaces are especially slippery
and may contribute to falls. Apply textured strips or appliqués
on the floors of tubs and showers. Use non-skid mats in the tub
or shower and on the bathroom floor. If you are unsteady on
your feet, use a stool with non-skid tips as a seat while
showering or bathing.
Grab bars can help you get into and out of your tub or shower,
and can help prevent falls. Check existing bars for strength and
stability and repair if necessary.
Attach grab bars, through the tile, to structural supports in the
wall, or install bars specifically designed to attach to the sides
of the bathtub. If you are not sure how it is done, get someone
who is qualified to assist you.
Check all electrical / telephone cords
Are lamp, extension and telephone cords placed out of the
flow of traffic?
Cords stretched across walkways may cause someone to trip.
Arrange furniture so that outlets are available for lamps and
appliances without the use of an extension cord, place it on the
floor against a wall where people cannot trip over it. Move the
phone so that telephone cords will not lie where people walk.
Are cords our from beneath furniture and rugs or carpeting?
Furniture resting on cords
Is there a telephone close to your bed?
In case of an emergency it is important to be able to reach the
telephone without getting out of the bed.
Are ash trays, smoking materials, or other fire sources
(heaters, hot plates, teapots, etc.) located away from beds
or bedding?
Burns are a leading cause of accidental death among seniors.
Smoking in bed is a major contributor to this problem. Don’t
smoke in bed or have hot liquids or other heat sources near the
Is anything covering your electric blanket when in use?
“Tucking in” electric blankets, or placing additional coverings
on top of them can cause excessive heat buildup that can start a
fire. Don’t set electric blankets so high that they could burn
Do you ever sleep with a heating pad that is turned on?
Never go to sleep with a heating pad if it is turned on, because
it can cause serious burns, even at relatively low settings.
Can damage them, creating fire and shock hazards.
Electric cords that run under carpeting may cause fire. Remove
cords from under furniture or carpeting. Replace damaged or
frayed cords.
Are cords attached to the walls or base boards with nails or
Nails or staples can damage cords, presenting fire and shock
hazards. Remove nails, staples, etc. Check wiring for damage.
Use tape to attach cords to walls or floors.
Do extension cords carry more than their proper load than
indicated by the ratings label on the cord and the
Overloading extension cords may cause fires. Standard 18
gauge extension cords can carry 1250 watts. If an extension
cord is needed, use one having a sufficient amp or wattage
rating. If the rating on the cord is exceeded because of the
power requirements of one or more appliances being used on
the cord, change the cord to a higher rated one or unplug some
Are heaters that come with a 3-prong plug being used in a
3-prong outlet or with a properly attached adapter?
The grounding feature provided by a 3-hole receptacle or an
adapter for a 2-hole receptacle is a safety feature designed to
lessen the risk of shock. Never defeat the grounding feature. If
you do not have a 3-hole outlet, use an adapter to connect the
heater’s 3-prong plug. Make sure the adapter ground wire or
tab is attached to the outlet.
Are small stoves and heaters placed where they can be
knocked over, and away from furnishings and flammable
materials, such as curtains or rugs?
Heaters can cause fires or serious burns if they cause you to
trip or if they are knocked over. Relocate heaters away from
passageways and flammable materials.
If your home has space heating equipment, such as
kerosene heater, a gas heater or an LP gas heater, do you
understand the installation and operating instructions
Unvented heaters should be used with room doors open or
window slightly open to provide ventilation. The correct fuel,
as recommended by the manufacturer, should always be used.
Vented heaters should have proper venting, and the venting
system should be checked frequently. Improper venting is the
most frequent cause of carbon monoxide poisoning and older
consumers are at special risk.
Check entrances and stairs
Are entrances safe?
Put bright lights over front and back doors, or install motion
sensor lights that come on when you approach. Replace dim or
burned out lights along pathways and halls. Oil or replace
locks and handles that don’t turn easily or are hard to grasp.
Install dead bolt locks on outside doors. Mark keys so they are
easy to identify.
Loose steps and cracked or uneven paving. Keep pathways and
steps free of hoses, newspapers and other clutter.
During an earthquake
If you are indoors get under a table, a desk or bed, or
brace yourself in a strong doorway. Watch for
falling, flying and sliding objects. Stay away from
If you are outdoors move to an open area away from
building, trees, power poles, and brick or block walls
and other objects that could fall.
If you are in an automobile, stop and stay in it until
the shaking stops. Avoid stopping near trees and
power lines, on or under overpasses.
If you are in a high rise building get under a desk
until the shaking stops. Do not use the elevator to
evacuate. Use the stairs.
If you’re in a store get under a table, or any sturdy
object, or in a doorway. Avoid stopping under
anything that could fall. Do not dash for the exit.
Choose your exit carefully.
Are stairs and pathways clear?
Put nonskid strips on the outer edge of steps, or paint the edges
white. Repair handrails that aren’t sturdy. Replace handrails
that don’t run the full length of the stairs. Repair broken or
If you must evacuate:
Prominently post a message indicating where you
can be found.
Take with you:
1. Medicines and first aid kit
2. Flashlight, radio and batteries
3. Important papers and cash
4. Food, sleeping bags/blankets
5. Extra clothing
6. Make arrangements for pets
After a disaster
Put on heavy shoes immediately to avoid injury from
stepping on glass or other debris
Check for injuries and give first aid
Check for fires and fire hazards
1. Sniff for gas leaks, starting at the hot water
heater. If you smell gas or suspect a leak, turn
off the main gas valve, open windows and
carefully leave the house. Do not turn lights on
or off, or light matches or do anything that
might make sparks. Note: Do not shut off gas
unless an emergency exists. If time permits call
the gas company or a qualified plumber. Do not
turn it back on until the gas company or
plumber has checked it out.
2. If water leaks are suspected shut off water at
main valve.
3. If damage to electrical system is suspected
(frayed wires, sparks, or the smell of hot
insulation) turn off system at main circuit
breaker of fuse box.
Check neighbors for injury
Turn on radio and listen for
advisories. Locate light source, if
Do not touch downed power lines or
objects touched by downed power
Clean up potentially harmful material.
Check to see that sewage lines are
intact before continued flushing of
Check house, roof, and chimney for
Check Emergency supplies.
Do not use phone except for genuine
Do not go sightseeing.
Be prepared for after shocks.
Open closets and cupboards carefully.
Cooperate with public safety officials.
Be prepared to evacuate when
Belladonna (Donnatal)
Diphenoxlate (Lomotil)
Hyoscyamine Sulfate
Propantheline Bromide
Metoclopramide (Reglan)
Cimetidine (Tagamet)
Bethanechol (Urecholine)
Take ½ hour before meals. May cause drowsiness. Avoid alcoholic beverages.
Take ½ hour before meals.
Avoid alcohol or other depressants such as tranquilizers and sedatives.
Same as atropine above.
Take ½ hours before meals.
Take ½ hour before meals. May cause drowsiness so avoid alcoholic beverages.
Take with or immediately after a meal.
Take on an empty stomach 1 hour before or 2 hours after meals.
Dioctyl Sodium
Sulfosuccinate (Colace)
(Effersyllium, Metamucil)
Take with 8 oz. of water.
Take with 8 oz. of water with meals.
Iron (Fergon, Feosol)
Potassium Chloride
Take on an empty stomach with water. If stomach upset occurs, take after meal or with food. Do not
take simultaneously with tetracycline or antacids.
May cause stomach upset. Take after meals or with food and a glass of water.
Chlorpropamide (Diabinese)
Tolbutamide (Orinase)
(DiaBeta, Micronase)
Take with milk or food. Avoid alcoholic beverages. May cause stomach upset.
Take with milk or food. Avoid alcoholic beverages. May cause stomach upset.
May cause stomach upset. Take ½ hour before meals. Avoid
alcoholic beverages.
Methyldopa (Aldomet)
Propranolol (Inderal)
Nitrates (Isordil, Sorbitrate)
Digoxin (Lanoxia)
Dipyridamole (Persantine)
(Quinaglute, Quinora)
Avoid natural licorice. (Most licorice in this country is artificial and not harmful, but imported
licorice candy and flavoring from Europe is often natural).
Take with food for best results. If being used for high blood pressure, avoid foods high in sodium or
Avoid alcoholic beverages. Take on an empty stomach 1 hour before or 2 hours after meals.
Take oral doses after morning meal. Avoid antacids, cough, cold, allergy and appetite suppressants.
Take 1 hour before meals with a full glass of water.
Take with food. May cause stomach upset.
Take with milk or food. May cause stomach upset. Include high potassium foods in diet (see below).
Furosemide (Lasix)
Take with milk or food with 8 oz. of water. Include high potassium foods in Diet (see below).
Spironolactone (Aldactone) Take with milk or food. May cause stomach upset.
Take with milk or food. May cause stomach upset. Include high potassium
(Diuril, Hydrodiuril)
foods in diet (see below).
Dried Beans
Bamboo Shoots
Brussel Sprouts
Veggie Juice
Dried Fruit
ASA (Aspirin, Empirin)
May cause stomach upset. Take with milk or food.
Take on an empty stomach. Causes drowsiness. Avoid alcoholic beverages. (Morphine, Codeine,
Phenazopyridine (Pyridium) Take ½ hour before meals with a full glass of water.
(Ceclor, Keflex)
Erythromycin Base
(E-mycin, Erytab, Eryc)
Stearate Estolate (Liosone)
(EES, Pedlamycin)
Metronidazole (Flagyl)
For best results, take on an empty stomach (1 hour before meals or
2 hours after meals). If stomach irritation occurs, take with food or milk.
Same as cephalosporins
Take on an empty or immediately before meals.
Absorption unaffected by food.
Absorption unaffected by food.
May cause stomach upset. Take with food. Nausea and vomiting may occur if taken with alcoholic
(Furadantin, Macrodantin) May cause stomach upset. For best results, take with milk or food.
Penicillin and Derivatives
Take on an empty stomach, 1 hour before meals or 2 hours after meals.
(Pen G, Pen Vee K, Pentids, Take with a full glass of water.
Ampicillin, Amoxicillin)
Avoid citrus foods, juices and carbonated beverages.
Tetracycline (Achromycin)
Avoid milk and milk products. For best results, take on an empty stomach, 1 hour before meals or 2
hours after meals.
Isocarboxazid (Marplan)
Tranylcypromine (Pamate)
Phenelzine (Nardil)
Avoid foods high in Tyramine.
Avoid foods high in Tyramine.
Avoid foods high in Tyramine.
Aged Cheese
Aged Meat
Chicken Liver
Cola Drinks
Pickled Herring
Sour Cream
Soy Sauce
(Coumadin, Dicoumarol)
Chloral Hydrate (Noctec)
Lithium Carbonate
(Lithan, Eskalith)
(Antivert, Bonine, Marezine)
Barbiturates (Phenobarbital)
Phenytoin (Dilantin)
Prednisolone (Delta-Cortef)
Prednisone (Deltasone)
Albuterol (Proventil)
Sulfa Drugs
May cause stomach upset. Take with food and water. Side effects are increased by caffeine
containing foods such as coffee, tea, cocoa and chocolate.
Avoid alcoholic beverages. Avoid foods high in Vitamin K: beef
liver, oils, green leafy vegetables (kale, brussel sprouts, cabbage, collards, spinach).
Avoid taking with salicylates.
May cause stomach upset, take with food. May cause drowsiness. Do not take concurrently with
alcoholic beverages.
Take with milk or food. May cause stomach upset.
May cause stomach upset, take with milk or food. May decrease the therapeutic effects of aspirin,
requiring dosage adjustment, if taken together.
May cause drowsiness. Do not take with alcoholic beverages. Take
after meals or with food or milk. Maintain adequate fluid and salt intake.
May cause drowsiness. Do not take with alcoholic beverages.
May cause drowsiness. Do not take with alcoholic beverages or medications containing
Take with food to increase absorption and reduce stomach irritation. Avoid alcoholic beverages.
Take with milk or food. May cause stomach upset.
Take with milk or food. May cause stomach upset.
Take with milk or food. May cause stomach upset.
Take with milk or food. May cause stomach upset. Avoid excessive protein.
Take on an empty stomach with 8 oz. of water.
Alprazolam (Xanax)
Avoid brussel sprouts, cabbage, cauliflower, kale, greens, rutabaga, soybeans and turnips.
Take with milk or food. Avoid alcoholic beverages. May cause stomach upset.
This pamphlet has been prepared for you by the Food & Nutrition management Services and Pharmacy
Management Services. It contains information about some common interactions that may occur between food and
drugs that you take. It does not attempt to discuss all possible food-drug interactions, nor does it list possible drugdrug interactions. For information regarding drug-drug interactions, you should consult your Pharmacist or
If you have questions regarding information in this pamphlet, contact your Physician, Pharmacist or Registered Dietitian at your hospital.
Food and Nutrition Management Services
6151 W. Century Blvd., Suite #916, Los Angeles, CA 90045
HR=High Risk Medication*
HR-INJ=High Risk Medication*
If administered via any route
if administrated IV/Subcu/IM
This is a list of medication classes commonly used by patients in geriatric care settings. Potential side
effects are provided for each medication class. High risk medication classes and individual high risk
medications according to ISMP’s (Institute of Safe Medication Practices) List of High Alert Medications
are indicated. This list in NOT all-inclusive. Consult the package insert of each medication for a complete
list of side effects.
1. Analgesics: Acetaminophen
Alkaline phosphates increased, liver dysfunction, leucopenia, neutropenia, pancytopenia, rash
Analgesics: Anti-Inflammatory Agents
Abdominal pain, anemia, bleeding, constipation, diarrhea, dizziness, dyspepsia, dyspnea, edema/fluid
retention, gastrointestinal ulceration, headache, hypertension, itching, liver function test (LFT’s)
increased, nausea, nervousness, palpitations, renal failure, somnolence, thrombosis, rash,
ringing/buzzing in the ears
3. Analgesics: Anti-migraine Agents
Bad taste (nasal spray), chest pain/tightness/heaviness, dizziness, ear/nose/throat disorders, fatigue,
flushing, hypertension, nausea, pain at the injection site (IM), paresthesias, throat discomfort, vasospasm
(ergot derivatives), vertigo, vomiting, warm sensation, weakness
4. Analgesics: Opioids
Blurred vision, bradycardia, confusion, constipation, dizziness, drowsiness, dry mouth, dyspnea,
fatigue, flushing (tramadol), headache, histamine release, hot flashes (tramadol), hypotension, itching,
miosis, nausea, nervousness, pain at the injection site (IM), palpitations, peripheral vasodilation,
physical and psychological dependence, rash, urination decreased, vomiting, weakness
5. Analgesics: Other
Angioedema (pregabalin), ataxia, blurred vision, and confusion, constipation, and creatinine kinase
increased (ziconotide), dizziness, double vision, drowsiness, edema, hallucinations (ziconotide),
headache, lightheadedness, memory impairment (ziconotide), muscle cramps, nausea, tremor, urinary
tract infections (ziconotide), weight gain (pregabalin), xerostomia
6. Analgesics: Topical
Allergic reaction, application site reaction, blanching, erythema, itching, stinging sensation, transient
burning on application
7. Analgesics: Urinary
Alopecia (pentosan), dizziness, gastrointestinal disturbances, headache, retinal hemorrhage (pentosan),
rash, stomach cramps
8. Anticoagulants: Heparin and Derivatives
Bleeding, erythema, fever, headache, hematoma, hemorrhage, heparin-induced thrombocytopenia with
thrombosis, histamine release, hypersensitivity reactions, injection site reaction, liver function tests
(LFT’s) increased
9. Anticoagulants: Other
Fondaparinux: anemia, bleeding, fever, injection site reaction, rash
Pentoxifylline: angina, confusion, depression, diarrhea, edema, headache, hypotension, nausea,
seizures, vomiting
10. Anticoagulants: Warfarin
Bleeding, hematuria, hemorrhage, hematoma, rash, skin necrosis (rare), transaminases increased
11. Anticonvulsants:
(Note: side effects vary with each medication; see package insert for additional information)
abdominal pain, abnormal gait, abnormal/blurred/double vision, alopecia, anorexia, ataxia, diarrhea,
dizziness, drowsiness, fatigue, headache, lethargy, memory decreased, nausea, nervousness, nystagmus,
paresthesia, somnolence, speech disorder, thrombocytopenia, tremor, vomiting, weakness
12. Antidementia Agents: Cholinesterase Inhibitors
Abnormal dreams, abdominal pain, anorexia, bradycardia, bruising, confusion, depression, diarrhea,
dizziness, eczema, headache, hypertension, infections, insomnia, liver function test (LFT’s)
abnormalities (tacrine), muscle cramps, nausea, urinary incontinence, vomiting
13. Antidemntia Agents: Other
Constipation, cough, dizziness, dyspnea, hallucinations, headache, hypertension, vomiting, weight loss
14. Antidepressants: Monoamine Oxidase Inhibitors (MAOI’s)
Anorexia, constipation, blurred vision, decreased sexual ability, diarrhea, dizziness, drowsiness,
edema, headache, impotence, insomnia, leucopenia, orthostatic hypotension, suicidal thinking/behavior,
tachycardia, thrombocytopenia, weakness, weight gain, xerosomia
15. Antidepressants: Other
(Note: side effects vary with each medication; see package insert for additional information), anxiety,
constipation, diarrhea, dizziness, headache, insomnia, nausea, somnolence, suicidal behavior/thinking,
tachycardia, tremor, weight gain/loss, xerostemia
16. Antidepressants: Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin Norepinephrine
Reuptake Inhibitors (SNRIs)
(Note: side effects vary with each medication; see package insert for additional information) anorexia,
anxiety, constipation, diaphoresis, diarrhea, dizziness, dry mouth, headaches, insomnia, nausea,
nervousness, rash, rhinitis, serotonin syndrome, sexual dysfunction, somnolence, suicidal
thinking/behavior, tremor, upper respiratory infections, vomiting, weakness, weight gain, xerostomia,
17. Antidepressants: Tricyclics and Teracycles
Anxiety, blurred vision, confusion, constipation, diarrhea, dizziness, drowsiness, dry mouth, ECG
changes, glucose control altered, increased intraocular pressure, narcoleptic malignant syndrome (NMS),
orthostatic hypotension, rash, sedation, suicidal thinking, urinary retention, weight gain, xerostomia
18. Antigout Agents:
Colchicine HR-INJ
Abdominal pain, alopecia (colchicines), anemia, (probenecid), anorexia, diarrhea, flushing, nausea,
rash, vomiting
19. Antihistamines: Non-sedating
Drowsiness (less than sedating antihistamines), dry mouth, fatigue, headache
20. Antihistamines: Sedating
Promethazine HR-INJ
Blurred vision, confusion, dizziness, drowsiness, dry mouth, dry skin, hypotension,
Syncope, thickening of bronchial secretions, urinary retention
21. Anti-Infectives: Aminoglycosides
Diarrhea, edema, gait instability, nausea, nephrotoxicity, neurotoxicity, ototoxicity, rash
22. Anti-Infectives: Antifungals
Abdominal pain, diarrhea, dizziness, fatigue, headache, nausea, thrombocytopenia
23. Anti-Infectives: Anti-Influenza Agents
Abdominal pain, diarrhea, dizziness, nausea, vomiting
24. Anti-Infectives: Cephalosporins
Abdominal pain, agitation, allergic reaction, confusion, diarrhea, dyspepsia, eosinophilia, flatulence,
headache, nausea, pain at the injection site (IV/IM), rash, thrombocytosis, transaminases increased,
25. Anti-Infectives: Macrolides
Abdominal pain, BUN increased, cramping, diarrhea, headache, nausea, rash, taste changes, vomiting
26. Anti-Infectives: Other
(Note: side effects vary with each medication; see package insert for additional information)
27. Anti-Infectives: Penicillins
Allergic reaction, anemia, confusion, diarrhea, drowsiness, insomnia, nausea, rash, tooth discoloration
(rare), transaminases increased, vomiting
28. Anti-Infectives: Quinolones
Abdominal pain, agitation, constipation, diarrhea, dizziness, drowsiness, headache, insomnia, liver
function test (LFT’s) increased, nausea, pharyngitis, rash, rhinitis, vomiting
29. Anti-Infectives: Sulfonamides
Allergic reaction, anemia, anorexia, diarrhea, dizziness, headache, itching, nausea, photosensitivity,
rash, vomiting
30. Anti-Infectives: Tetracyclines
Abdominal cramping, allergic reactions, anorexia, diabetes insipidus (rare), diarrhea, dizziness, hearing
loss, hepatoxicity, nausea, photosensitivity, rash, renal impairment, tooth discoloration, vomiting
31. Anti-Infectives: Tuberculosis Agents
(Note: side effect vary by each medication; see package insert for additional information), anorexia,
dizziness, edema, flushing, headache, nausea, rash, vomiting
32. Anti-Parkinson’s Agents: Anticholinergics
Blurred vision, confusion, constipation disorientation, dry skin, glaucoma, memory impairment,
nausea, tachycardia, urinary retention, vomiting, xerostomia
33. Anti-Parkinson’s Agents: Catechol-O-Methyl Transferase (COMT) Inhibitors
Abdominal pain, constipation, diarrhea, dizziness, dyskinesias, dyspnea, fatigue, nausea, orthostatic
hypotension, somnolence, urine discoloration, vomiting
34. Anti-Parkinson’s Agents: Dopamine Agonists
(Note: side effects vary with each medication; see package insert for additional information),
abnormal/excessive dreaming, anorexia, anxiety, blurred vision, confusion, diarrhea, fatigue, nausea,
orthostatic hypotension, somnolence, syncope, vomiting
35. Anti-Parkinson’s Agents: Monoamine Oxidase B (MAOB) Inhibitors
Arthralgia, constipation, depression, dyskinesia, dyspepsia, flu-like symptoms, hallucinations,
headache, nausea, orthostatic hypotension, vertigo, weight loss, xerostomia
36. Antipsychotics: Atypicals
(Note: side effect vary with each medication; see package insert for additional information), agitation,
anxiety, cholesterol increased, constipation, dizziness, drowsiness, dyspepsia, extrapyramidal symptoms
(EPS), headache, hypotension, insomnia, prolactin increased, rhinitis, somnolence, tachycardia, tremor,
urinary incontinence or retention, weakness, weigh gain, xerostomia.
37. Antipsychotics: Lithium
Anorexia, ataxia, blackout spells, cardiac arrhythmia, diarrhea, dizziness, dry or thinning hair, dry
mouth, euthyroid goiter and/or hypothyroidism, frequent urination, headache, hyperglycemia,
leukocytosis, nausea, thirst, tremor, vomiting, weight gain
38. Antipsychotics: Typicals
Blurred vision, confusion, constipation, depression, dizziness, drowsiness, dry mouth, ECG changes,
extrapyramidal symptoms (EPS), hypotension (especially orthostatic), neuroleptic malignant syndrome
(NMS), prolactin increased, rash, sedation, sexual impairment, tachycardia, tardive dyskinesia, urinary
retention, weight gain
39. Antirheumatic Agents:
(Note: side effect vary with each medication; see package insert for additional information), abdominal
pain, dizziness, headache, nausea, rash, vomiting, weakness
40. Antithyroid Agents:
Arthralgia, constipation, dizziness, edema, headache, jaundice, myelosuppresion, nausea, rash,
41. Anxiolytics: Benzodiazepines and Meprobamate
Midazolam HR-INJ
Behavior problems, blurred vision, change in appetite, decreased salivation, depression, dizziness,
drowsiness, dry mouth, edema, headache, irritability, lightheadedness, memory impairment, paradoxical
excitation, pronunciation difficulties, respiratory depression, sedation, sexual dysfunction, weight
gain/loss, urinary retention
42. Anxiolytics: Buspirone
Blurred vision, diarrhea, dizziness, drowsiness, headache, muscle weakness, nausea, rash
43. Appetite Stimulants:
Acne, diarrhea, electrolyte disturbances, excitation, flatulence, fluid retention, headache hepatotoxicity,
hirsutism, hoarseness, hypertension, insomnia, libido increased/decreased, nausea, rash, vomiting,
weight gain
44. Attention Deficit Hyperactivity Disorder (ADHD) Agents
Abdominal pain, appetite decreased, chest pain, constipation, diarrhea, dizziness, headache, insomnia,
nausea, nervousness, sexual dysfunction, tachycardia, vomiting, weight loss, xerostomia
45. Blood Formation Agents
Abdominal pain, alopecia, angina, athralgia, bone pain, constipation, diarrhea, dizziness, dyspnea,
edema, fatigue, fever, headache, hypertension, hypotension, infection, myalgia, mucositis, nausea,
neutropenic fever, rash, vomiting
46. Cardiovascular Agents: Alpha-1 Blockers
Abdominal pain, diarrhea, dizziness, edema, fatigue, headache, orthostatic hypotenstion, respiratory
tract infection, sexual dysfunction, somnolence, vertigo
47. Cardiovascular Agents: Alpha-2 Adrenergic Agonists
Anxiety, dizziness, drowsiness, dry mouth, edema, fatigue, headache, liver function test (LFT)
changes, nausea, orthostatic hypotension, sedation, sexual dysfunction
48. Cardiovascular Agents: Angiotensin II Receptor Blockers (ARBs)
Abdominal pain, anemia, chest pain, cough (lower incidents than ACE inhibitors), diarrhea, dizziness,
fatigue, headache, hyper/hypoglycemia, hyperuricemia, hypotension, nausea, rash, serum creatinine
increases, urinary tract infection, vomiting, weakness
49. Cardiovascular Agents: Angiotensin-Converting Enzyme (ACE) Inhibitors
Abdominal pain, BUN increase, chest pain, cough, diarrhea, dizziness, fatigue, headache,
hyperkalemia, infections, nausea, orthostatic hypotension, rash, vomiting
50. Cardiovascular Agents: Antiarrhythmic Agents (HR-INJ)
(Note: side effects vary with each medication; see package insert for additional information), abnormal
liver function test (LFTs), arrhythmia, bradycardia, dizziness, dyspnea, hypotension, nausea, paresthesia,
photosensitivity, pulmonary infiltrate/fibrosis, visual disturbance, vomiting
51. Cardiovascular Agents: Antihypotensives
Abdominal pain, chills, dysuria, pain, paresthesias, pruritis, rash, supine hypertension, urinary
52. Cardiovascular Agents: Beta Blockers (HR-INJ)
Bradycardia, confusion, chest pain, constipation, depression, diarrhea, dizziness, dyspnea, edema,
fatigue, headache, hypotension, impotence, insomnia, mental impairment, nausea, pruritis, rash, stomach
53. Cardiovascular Agents: Calcium Channel Blockers (HR-INJ)
Angina, arrhythmias, dizziness, edema, fatigue, flushing, headache, hypotension, myocardial
infarction, nausea, palpitations, somnolence
54. Cardiovascular Agents: Digoxin (HR-INJ)
Abdominal pain, confusion, depression, diarrhea, dizziness, headache, nausea, ventricular
tachycardia/fibrillation, visual disturbances (blurred or yellow vision), vomiting
55. Cardiovascular Agents: Vasodilators
Nitroprusside HR-INJ
(Note: side effects vary with each medication; see package insert for additional information), anxiety,
arrhythmia, dizziness, flushing, headache, hypotension, nausea, tachycardia
56. Chemotherapy: Cytotoxic Agents (Oral) HR
Methotrexate, oral (Non-oncologic use) HR
(Note: side effects vary with each medication; see package insert for additional information), alopecia,
anorexia, bone marrow suppression, cardiotoxicity, diarrhea, electrolyte and endocrine imbalance, fever,
gastrointestinal ulceration, gynecomastia, hematologic effects, hepatic effects, hypersensitivity
reactions, hypertension, hypotension, infection, mucositis, muscle and joint pain, nausea, peripheral
neuropathy, pulmonary infiltrates, renal effects, vomiting
57. Cholesterol-Lowering Agents: Fibrates
Abdominal pain, back pain, constipation, dyspepsia, fatigue, headache, hepatic enzymes increased,
rash, respiratory, disorder, rhinitis
58. Cholesterol-Lowering Agents: Other
(Note: side effects vary with each medication; see package insert for additional information), bloating,
constipation, edema, flushing (niacin), headache, LDL cholesterol increased (omega-3 acid)
59. Cholesterol-Lowering Agents: Statins
Abdominal pain, arthralgia, chest pain, constipation, diarrhea, dizziness, edema, flu-like symptoms,
headache, hepatic enzymes increased, insomnia, myalgia, rash, respiratory infections, sinusitis
60. Diabetes Agents (Oral): Metformin
Abdominal discomfort, diarrhea, dyspnea, flatulence, headache, hypoglycemia, lactic acidosis (rare),
myalgia, nausea, palpitations, rash, vomiting, weakness
61. Diabetes Agents (Oral): Other
(Note: side effects vary with each medication; see package insert for additional information),
abdominal pain, diarrhea, flatulence, hepatic enzymes increased, nausea
62. Diabetes Agents (Oral): Sulfonylureas (HR)
(Note: side effects vary with each medication; see package insert for additional information), anxiety,
dizziness, edema, headache, hypoglycemia, hyponatremia, nausea, rash, vomiting, weakness
63. Diabetes Agents (Oral): Thiazolidinediones
Back pain, cholesterol levels increased, edema, fatigue, fracture risk, headache, heart failure,
hyperglycemia, hypoglycemia, liver function test (LFT) elevations, respiratory infection, tooth disorder,
weight gain
64. Diabetes Agents (Injectible): Insulin
Atrophy of subcutaneous fat tissue, edema, fatigue, headache, hypoglycemia, hypokalemia, injectionsite reactions, itching, palpitations, rash, tachycardia
65. Diuretics: Loop
Allergic reaction, anemia (rare), blurred vision, dizziness, headache, hearing impairment,
hyperglycemia, hypotension, electrolyte and fluid imbalance, orthostatic hypotension, urinary frequency
66. Diuretics: Potassium-Sparing
(Note: side effect vary with each medication; see package insert for additional information), allergic
reactions, drowsiness, edema, electrolyte disturbances, gynecomastia (spironolactone), lethargy, mental
confusion, nausea, rash, vomiting
67. Diuretics: Thiazides
Abdominal pain, allergic reaction, anemia, anorexia, chest pain, dizziness, drowsiness, electrolyte
disturbances, hypokalemia, joint pain, orthostatic hypotension, photosensitivity, volume depletion
68. Gastrointestinal Agents: Antiacids
Abdominal cramps, constipation (more likely with calcium and aluminum), diarrhea (more likely with
magnesium), fecal impaction, headache, mineral disturbances, rebound hyperacidity, renal dysfunction
69. Gastrointestinal Agents: Antidiarrheals
Opium Tincture (HR)
Abdominal destention, anxiety, constipation, discoloration on tongue, drowsiness, dry mouth, fecal
impaction, INR changes, restlessness, urinary retention
70. Gastrointestinal Agents: Antiemetics
Anxiety, constipation, diarrhea, dizziness, drowsiness, fever, gynecologic disorder, headache, hepatic
enzymes increased, hiccups, malaise/fatigue, pruritis, rash, urinary retention
71. Gastrointestinal Agents: Antispasmodics
Abdominal cramps, blurred vision, confusion, constipation, diarrhea, dizziness, drowsiness, dry eyes,
dry skin, headache, impotence, nausea, palpitations, rash,
Tachycardia, urinary retention, weakness
72. Gastrointestinal Agents: Histamine 2 Blockers
Agitation, anemia (rare), confusion, constipation, diarrhea, dizziness, gynocomastia, headache, liver
function test (LFTs) increased, rash, somnolence
73. Gastrointestinal Agents: Inflammatory Bowel Disease (IBD)
Abdominal pain, arthralgia, chest pain, chills, edema, diarrhea, dyspepsia, dizziness, headache,
insomnia, myalgia, nausea, pharyngitis, photosensitivity, vomiting
74. Gastrointestinal Agents: Laxatives
Abdominal cramping, bloating, diarrhea, electrolyte and fluid imbalance, flatulence
75. Gastrointestinal Agents: Pancreatic Enzymes
Abdominal pain, cramps, flatulence, loose stool, nausea, vomiting
76. Gastrointestinal Agents: Promotility Agents
Anemia (rare), bradycardia, breast tenderness (metoclopramide), diarrhea, drowsiness, extrapyramidal
symptoms (EPS), fatigue, rash, restlessness, weakness
77. Gastrointestinal Agents: Protectants
Abdominal cramping, constipation, diarrhea
78. Gastrointestinal Agents: Proton Pump Inhibitors
Abdominal pain, diarrhea, dizziness, flatulence, headache, nausea, rash, regurgitation, respiratory
infection, vomiting
79. Gastrointestinal Agents: Stool Softener
Abdominal cramping, diarrhea, throat irritation
80. Hormones: Estrogen and Progestins
Bloating, cancer (breast, cervical, ovarian), depression, diarrhea, dizziness, edema, headache,
hirsutism, hypertension, nausea, pancreatitis, stroke, thromboebolism, weight gain, withdrawal bleeding
81. Hormones: Thyroid Replacement Agents
Hyperthyroid: weight loss, nervousness, sweating, tachycardia, insomnia, heat intolerance,
palpitations, vomiting, seizures, arrhythmia
Hypothyroid: weight gain, pussy face, cold intolerance, depression, abdominal bloating, cold hands
and feet, dry or thinning hair, joint or muscle pain
82. Hypnotics/Sedatives: Barbiturates and Chloral Hydrate (HR)
Abnormal dreams, allergic reactions, ataxia, bradycardia, confusion, constipation, drowsiness,
hallucinations, hangover effect, headache, hypotension, myelosuppression,
Nausea, nightmares, palpitations, physical and psychological dependence, respiratory depression,
somnolence, vomiting
83. Hypnotics/Sedatives: Other
Abnormal dreams, anxiety, ataxia, confusion, depression, diarrhea, dizziness, drowsiness,
hallucinations, hangover effect, headache, infections, nausea, nervousness, rash, sexual dysfunction,
somnolence, unpleasant taste, vomiting, xerostomia
84. Iron Replacement (Oral)
Constipation, dark stools, nausea, stomach cramping
85. Multiple Sclerosis Agents:
(Note: side effects vary with each medication; see package insert for additional information), anxiety,
arthalgia, asthenia, back pain, bradyarrhythmia, chest pain, diarrhea, dizziness, dyspnea, headache,
infections, insomnia, liver dysfunction, macular edema, nausea, pain, palpitations, pruritis, rhinitis,
shortness of breath, urinary tract infections, vasodilatation, weakness
86. Ophthalmic Agents: Antibiotics
(Note: side effects vary with each medication; see package insert for additional information), decreased
visual acuity, eye discomfort, foreign body sensation, hyperemia, pain, pruritis
87. Ophthalmic Agents: Antiglaucoma Agents
(Note: side effects vary with each medication; see package insert for additional information), decreased
visual acuity, eye discomfort, foreign body sensation, hyperemia, pain, pruritis
88. Ophthalmic Agents: Steroids
(Note: side effects vary with each medication; see package insert for additional information), decreased
visual acuity, eye discomfort, foreign body sensation, hyperemia, pain, pruritis
89. Osteoporosis Agents: Bisphosphonates
Abdominal pain, acid reflux, constipation, diarrhea, electrolyte disturbances, esophageal ulcer,
flatulence, flu-like symptoms, headache, hypertension, hypo/hypercalcemia, hypophosphatemia,
indigestion, muscle cramps, nausea, rhinitis, osteonecrosis of the jaw (rare), pain, vomiting
90. Osteoporosis Agents: Calcitonin
Anorexia, angina, constipation, diarrhea, dizziness, facial flushing, fatigue, infections, myalgia, nausea,
rhinitis, skin irritation
91. Osteoporosis Agents: Calcium Supplements
Constipation, headache, hypercalcemia, hypophosphatemia, nausea, thirst, vomiting
92. Osteoporosis Agents: Other
Arthalgia, diarrhea, dizziness, hypertension, hypocalcemia, hypotension, myalgia, nausea, rash, spasm,
syncope, vomiting
93. Osteoporosis Agents: Selective Estrogen Receptor Modulators (SERMs)
Chest pain, flu symptoms, headache, hot flashes, infection, joint pain, nausea
94. Osteoporosis Agents: Vitamin D
Constipation, headache, irritability, myalgia, nausea, pruritis, somnolence, thirst, vomiting
95. Potassium Supplements (Oral)
Abdominal pain/discomfort, diarrhea, flatulence, gastrointestinal bleeding/obstruction/perforation
(when used orally), hyperkalemia, nausea, rash, vomiting
96. Respiratory Agents: Anticholinergics
Abdominal pain, abnormal taste, constipation, dry nasal mucosa, dyspepsia, edema, infections,
myalgia, nasal congestion, rash, vomiting, xerostomia
97. Respiratory Agents: Bronchodilators
Anxiety, dizziness, dry mouth, gastrointestinal pain/discomfort, headache, insomnia, nausea,
nervousness, palpitations, tachycardia, taste loss/disturbance, throat irritation, tremor
98. Respiratory Agents: Other
(Note: side effects vary with each medication; see package insert for additional information)
99. Respiratory Agents: Steroids
Acne, adrenal suppression, bronchospasm, dizziness, dysturia, headache, hypertension, insomnia,
nausea, oral candidiasis/thrush, palpitations, psychiatric disturbances, respiratory infection, rhinitis
100. Respiratory Agents: Steroids (Nasal)
Acne, adrenal suppression, bronchospasm, dizziness, dysturia, headache, hypertension,
Insomnia, nasal irritation, nausea, palpitations, psychiatric disturbances, respiratory infection, rhinitis
101. Skeleton Muscle Relaxant:
Ataxia, blurred vision, confusion, constipation, dizziness, drowsiness, dry mouth, fatigue, headache,
hypotension, hypotonia, insomnia, nausea, polyuria, psychiatric disturbances, rash, slurred speech,
somnolence, vertigo, weakness, xerostomia
102. Steroids:
Acne, appetite change, edema, electrolyte disturbances, dizziness, dysturia, fat distribution, fatigue,
flu-like symptoms, fracture, gastroenteritis, headache, hyperglycemia, hyperkinesis, hypertension,
infections, insomnia, mood swings, moon face, nausea, nervousness, oral candidiasis/thrush,
tachycardia, taste perversion, weight gain, xerostomia
103. Steroids (Topical):
Acne-form eruptions, allergic contact dermatitis, burning/itching upon application, dryness, folliculitis,
itching, hypertrichosis, hypopigmentation, skin infection (secondary), skin maceration, skin atrophy
104. Urinary Agents: Antispasmics
Blurred vision, confusion, constipation, drowsiness, dysturia, fatigue, headache, intraocular pressure
increased, leucopenia, nausea, nervousness, palpitations, rash, tachycardia, vertigo, vomiting
105. Urinary Agents: Benign Prostatic Hypertrophy (BPH)
Abdominal pain, diarrhea, dizziness, edema, fatigue, headache, orthostatic hypotension, respiratory
tract infection, sexual dysfunction, somnolence, vertigo
106. Urinary Agents: Urinary Incontinence
Blurred vision, constipation, diarrhea, dry eyes, dry mouth, dyspepsia, dizziness, fatigue, headache,
insomnia, nausea, nervousness, rhinitis, somnolence, urinary retention, weakness, xerostomia
107. Analgesics: Aspirin
Angioedema, bleeding, bronchospasm, gastrointestinal ulceration, Reye’s syndrome, tinnitus
108. Anticoagulants: Thrombin Inhibitor (HR)
Anemia, angina, bleeding, bradycardia, chest pain, diarrhea, dyspnea, fever, gastrointestinal reactions,
heart failure, hemorrhage, hypotension, nausea, pain, pulmonary embolism, thrombosis, ventricular
tachycardia, vomiting
109. Anti-Infectives: Antivirals
Anemia, cough, diarrhea, fever, nausea, nephrotoxicity, neuropathy, neutropenia, rash, retinal
detachment, thrombocytopenia, tremor, vomiting
110. Antiplatelet Agents (HR):
(Note: side effects vary with each medication; see package insert for additional information),
arthralgia, atrial fibrillation, back pain, chest pain, constipation, diarrhea, gastrointestinal bleeding,
headache, hypercholesterolemia, hypertension, hypotension, liver function test (LFT) abnormalities,
myocardial infarction, pruritis, rash
111. Cardiovascular Agents: Calcium Channel Blockers (non-dihydropyridine)
Bradyarrhythmias, congestive heart failure, constipation, cough, dizziness, edema, fatigue, headache,
heart block, hepatoxicity, hypotension, myocardial infarction, sinusitis
112. Cardiovascular Agents: Other
(Note: side effects vary with each medication; see package insert for additional information),
constipation, cough, creatine kinase increased, diarrhea, dizziness, headache, hypotension, rash, syncope
113. Chemotherapy: Hormonal Agents (HR)
(Note: side effect vary with each medication; see package insert for additional information), breast
tenderness, constipation, depression, diarrhea, endometrial cancer, fatigue, fluid retention, hepatic effect,
hot flashes, gynecomastia, headache, hypersensitivity reactions, insomnia, menstrual irregularities,
muscle and joint pain, nausea, sweating, thromboembolism, vaginal discharge, vomiting
114. Diabetes Agents (Injectible): Other
(Note: side effects vary with each medication; see package insert for additional information), acute
renal failure, allergic reaction, antibody development, diarrhea, dizziness, headache, hypoglycemia,
indigestion, nausea, nervousness, pancreatitis, upper respiratory infection, vomiting
115. Erectile Dysfunction Agents:
Epistaxis, erythema, flushing, headache, hearing decreased, indigestion, insomnia, priapism, retinal
hemorrhage, rhinitis, visual disturbances
116. Gastrointestinal Agents: Antiflatulents
Diarrhea, nausea, vomiting
117. Gastrointestinal Agents: Irritable Bowel Syndrome (IBS)
Abdominal pain, bowel obstruction, chest pain, constipation, diarrhea, headache, hypotension,
ischemic colitis, nausea, syncope
118. Hormones: Estrogens
Bloating, cancer (breast, cervical, ovarian), depression, diarrhea, edema, headache, hirsutism,
hypertension, nausea, pancreatitis, thromboembolism, weight gain, withdrawal bleeding
*The High-Risk (HR and HR-INJ) Medications noted on this form represent medications on the
Institute for Safe Medications Practices (ISMP) “List of High-Alert Medications” most commonly used
in the home care/community setting. Refer to the ISMP web site for the complete list of High-Alert
Medications, including IV epinephrine, TPN’s and Sterile Water: disease, myocardial infarctions. Comments –
Email: [email protected]
Fire & Rescue, Police, Sheriff and Highway Patrol,
Ambulance and Paramedics
Press the space bar until someone answers.
Oprima la barra espaciadora hasta que alguien le conteste.
Physician: _________________ Pharmacy: ________________ Ambulance: _____________
Other important phone numbers:
The Joint Commission 24 Hour Hotline 800-­‐994-­‐6610 California Department of Public Health Services 24 Hour Hotline 1(800)-­‐228-­‐1019 PATIENT RESOURCES/EMERGENCY NUMBERS
Your Home Health Care Agency is: Privé Care.
Tel: (877) 741-9535
Privé Care staff is proud to have the opportunity to provide home health services to you. The following information will help you
understand how to call for help in urgent or emergency situations.
Remain in a safe place. Turn your radio dial to
KISS RADIO LA at 102.7 or 1150 AM or call (818) 845-1027 or (818) 520-1027.
While receiving your services, someone from Privé Care will be contacting you.
Emergencies are referred to acute care facilities.
Emergency Numbers
Paramedic, Fire, Police, Ambulance Companies
Med Trans
(818) 990-5555
(818) 984-0777
(805) 495-4668
(818) 781-0992
(805) 327-4111
(213) 622-4445
(310) 404-8700
(310) 921-1416
Sunset Bus
Empire Trans Med
American Red Cross
(818) 375-1700
(213) 739-5555
(800) 540-4000
(213) 368-4000
(213) 738-4004
(800) 228-1019
(800) 222-2225
(800) 399-4529
(800) 339-6993
(213) 686-0950
(213) 485-6334
(800) 638-6833
(800) 772-1213
Child Abuse Hotline
Department of Aging (City)
Department of Aging (County)
Department of Health Services (Home Health Hotline)
National Institute of Aging
Legal Aid Foundation
LA info Line for Community Services/Resources
Mayor’s Office for the Disabled (Info: Handicap Stickers)
Medicare Hotline
Social Security Office
Patient Resources
MEDICAL SERVICES (Physical, Mental, Pharmacies) Medical Information (Health Center Referral)
National Institute for Drug Abuse
Nursing Home Information and Referral Service
Pharmacy 24 Hour Savon-Drug Referral Line
Fair Housing Council
HUB User (Info on Elderly & Handicapped Housing)
Emergency Shelter
Emergency Food
Food Stamp Application Information Line
Salvation Army –
Los Angeles
San Fernando
(213) 250-8055
(800) 662-4357
(800) 777-2866
(800) 627-2866
(818) 373-2285
(800) 245-2691
(213) 686-0950
(213) 686-0950
(213) 686-0950
(818) 246-5586
(213) 484-7775
(818) 781-3300
Bell Taxi
City Ride
LA Transportation Authority (information on Bus/Rail)
Metro Access
(800) 666-6664
(213) 483-5372
(800) 266-6883
(800) 827-0829
These referral sources are given to the patient/caregiver for emergencies.
Privé Care has 24-hour on-call availability by calling: (877) 741-9535
Was this manual useful for you? yes no
Thank you for your participation!

* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project

Download PDF