Discharge Plan Format

Discharge Plan Name:________________________

Age: ____ Sex:____ Religion:_______________

Diagnosis: ___________________ __ Surgery Undergone, if any:____________________ ________________________ Hospital: _____________________

____________________________ Rm./Ward-Bed No. ___________Physician:______________

A. Objectives

B. 1. Medications (attached a separate sheet for this purpose if needed) Name of drug

Dosage and Frequency

Route

Curative Effects

Side Effects

2. Exercise / Activity Type of Activity Allowed / to be continued:__________________________________ :__________________________________ __________________________________ Procedure or Steps: _______________________________________________________________________ _______________________________________________________________________ __ Use of Equipment (if any):__________________________________________________ Restrictions:_____________________________________________________________ 3. Treatment (prescribed treatment to be continued at home or to a referred health institution.)

4. ( ( ( (

Health Teachings (provide a separate sheet on specified health teachings) ) clinic appointments schedule ( ) use of alternative medicines ) follow up laboratory examinations ( ) relapse prevention measures ) understanding and knowing what to do with side effects of medications ) others __________________

5. a.. Observed signs and symptoms that need reporting: ________________________________________________________________________ ________________________________________________________________________

b. Interventions / Home Remedies that may be done immediately prior to seeking consultation:________________________________________________________________ __________________________________________________________________________ 6. Diet (prescribed by the doctor / dietician). a. Prescribed Diet: b. Restrictions:

7. Spiritual and Psychological Needs ( ) Spiritual Counseling ( ) Confession ( ) Supportive Counseling ( ) Grief Work ( ) Family Therapy ( ) Join Organizations/ Church Activities ( ) Anger Management ( ) Reconciliation of Conflicted Relationships A. Discharge Details a. Date and Time of Discharge: __________________________________________________ b. Accompanied by: ___________________________________________________________ c. Mode of Transportation: ______________________________________________________ d. General Condition upon Discharge: _____________________________________________ __________________________________________________________________________ __________________________________________________________________________ THESE DISCHARGE INSTRUCTIONS WERE EXPLAINED TO THE PATIENT AND/ OR RELATIVE Read and Understood: _________________________________ PATIENT/ RELATIVE (Signature over printed name)

Validated:

_________________________________ STUDENT NURSE (Signature over printed name)

_________________________________ CLINICAL INSTRUCTOR (Signature over printed name)