Your life. Your plan.
A nurse who helps with hospital support
Use the prompts that are helpful to you. You can write, draw, or ask someone to record your own words.
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My visit and contact
Appointment or ward, relevant dates, liaison contact and working hours. Keep unnecessary personal information off shared copies.
What helps me understand
Communication method, processing time and equipment needed. Include how I show pain, refusal or uncertainty.
Adjustments we are asking for
Describe the barrier and the change that would help. Record what the department has agreed.
Who will arrange each adjustment
Named role, action and date. Ask who covers support outside liaison hours.
Everyday care on the ward
Who will help with meals, drinks, medicines, toileting, moving and communication? Record supporters’ availability accurately.
Decisions and involvement
Questions about treatment, help needed to understand, chosen supporters and any advocacy referral. This worksheet does not give consent.
Preparing to leave hospital
Support, transport, equipment, medicines and follow-up. Record who is responsible and unresolved concerns.
Checking and sharing the plan
Ask how agreed needs reach the right staff, including at handover. Record the review date and safe sharing arrangements.