DA form 4700 template - U.S. Army
|PATIENT/FAMILY TEACHING FORM |
|(OUTPATIENT) |
|Documentation codes |
|LEARNER: |METHOD: |EVALUATION: |
|Pt =Patient |V = Videotape G = Group |V = Verbalize instruction |
|Sp = Spouse |1 =1:1 Discussion O = Other |D =Demonstrates : no assistance needed |
|M = Mother |D =Demonstration |DP = Demonstrates w/physical assistance |
|F = Father |A = Audio-tape |DV = Demonstrates w/verbal assistance |
| |P = Printed Instruction |NR = Needs reinforcement |
| | |N = No evidence of learning |
|DATE |LEARNER |EDUCATION NEEDS |METHOD |EVALUATION |SIGNATURE |
| | |Asthma “Survival Skills” | | | |
| | |1. Identify early warning signs of an asthma | | | |
| | |attack |V/D/P |V/D | |
| | |2. Demonstrate the correct technique for | | | |
| | |using a press and breathe inhaler with and |V/D/P |V/D | |
| | |without spacer | | | |
| | |3. Identify quick relief and long term | | | |
| | |controller medications |V/D/P |V/D | |
| | |4. Demonstrate correct techniques for using | | | |
| | |a peak flow meter |V/D/P |V/D | |
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