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)

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