DISCHARGE PLAN
Is this an Outpatient Discharge Only?
Pre-printed instructions
Pediatric Specific Handout
Discharge Instructions: (free text)
Call your doctor if you experience: (free text)
Activity Restrictions?
Restrictions: (free text)
Was a copy of the latest ECG during this hospitalization, sent home with the Patient?
Eligible for Outpatient Cardiac Rehab?
Lab/Xray
Treatments/Wound Care?
List: (free text)
Other: (free text)
Special Diet?
Diet: (free text)
Monitor Weight
Next provider required to meet medication follow-up.
Next Provider
Unlisted Provider: (free text)
FOLLOW-UP APPOINTMENTS
(Physicians, Clinics, Radiology, Lab, and Community and Home Services)
PCP
Specialty
Purpose:
When:
Address:
Phone:
Provider Other:
Specialty
Purpose:
When:
Address:
Phone:
More Appointments?
Special arrangements for discharge
Community Resource:
Community Resource contact person:
Community Resource Phone:
Home supplies/equipment:
Company/Phone #:
Infusion Company:
DC From:
DC To:
Assistive Devices
Vision-Disposition
Hearing-Disposition
Dental-Disposition
Prescriptions received
Medications sent home
Rx/Meds called to Pharmacy?
Name of Patients Pharmacy(s)/Location(s):
Outcome of (Vaccine) Screening
Pre-authorized order for Influenza vaccine?
Suggested MD order for Influenza vaccine?
Patient excluded; NOT eligible for Influenza vaccine?
Have you had the Influenza (Flu) Vaccine this season/ Not Applicable
Pre-authorized order for Pneumococcal vaccine?
Suggested MD order for Pneumococcal vaccine?
Patient excluded; NOT eligible for Pneumococcal vaccine?
Have you ever had the Pneumococcal (Pneumonia) Vaccine
Primary DATE:
Booster Date:
Immunizations given?
Vaccine(s) information given to patient?
Patient able to comprehend?
Document Discharge Medications?
Medication
Dosage:
Route
Frequency
Indication for Med
Last Taken:
Time:
Instructions:
(Repeated as necessary)
NURSING DISCHARGE SUMMARY**
1. Status At Time Of Discharge:
Assessment summary of appropriate system factors (i.e., Physical, ADLS, Psychosocial)
IV DC'd If Applicable:
Pain Comment:
Patient's Pain Scale At Discharge:
2. Evaluation Of Patient Plan Of Care: (Outcomes/Focus Of Care)
(Note unresolved outcomes, continuing care needs, referrals)
3. Discharged To:
With Whom:
Via:
POLST form returned to patient upon discharge:
Discharge instructions/educational material given to:
patient/caregiver regarding the following:
Follow up with a physician after Discharge:
Diet/Fluid Intake:
Activity Level after Discharge:
Discharge Medications:
Weight Monitoring Instructions:
What to do if symptoms worsen:
Discharge Comment: (free text)