Discharge summary
Discharge Summary
Date:
Medication Route/schedule Instructions/side effects
(include drug, route of administration, and instructions)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Treatments/procedures:
Activity:
Problems to report to provider: (list signs/symptoms pertinent to client diagnosis)
Diet:
Follow-up:
Referrals:
Personal belongings given to:
Dentures Hearing aid Glasses/contacts
Verbalizes understanding of present physical condition? Yes No
Verbalizes understanding of discharge instructions? Yes No
The above discharge instructions have been explained and a copy has been provided to me
Client/significant other
Mode of transport: Discharged via: stretcher, amb., w/c
Accompanied by:
Destination: With whom: Departure time:
Nurse’s signature:
