Hospital Discharge Form

Hospital Discharge Form
Basic Information
Complete this form for all hospital discharges. Refer to Hospital Discharge Summary Form Instructions for information on how to complete this form.
Patient's I.D. #
Patient's Name

First Name Last Name
Phone Number:

Area Code Phone Number
Attending Physician

First Name Last Name
Facility Name
Date services ends

Month Day Year
Date
Discharge Checklist (Make sure applicable information below are documented in the record)

Discharge readiness attested to by Physician Discharge plan discussed with family & attending provider Clear description of discharge plan in place Therapy notes (if applicable)

Medical Information
Kindly fill details about the patient’s current medical condition and state why [Name of Facility] services are no longer needed for this patient. (Use full sentences, plain language and no abbreviations)
a. Date admitted to [Name of Facility]

Month Day Year
b. The symptoms you presented with at admission include
c. Below is what you were diagnosed with
d. Below is what you were treated with
e. Your tests and corresponding results include
f. The person who evaluated you is
g. Your current treatment plan include
h. Here is the medical issue resolved
i. With your improved condition, your needed care can be safely provided in/at
i. Here is your discharge plan and follow-up care includes
Other Information
Name of person completing the form

First Name Last Name
Phone Number

Area Code Phone Number
Signature of person completing the form
Should be Empty: