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Discharge Plan: Name of Drug Dosage and Frequency Route Curative Effects Side Effects
Discharge Plan: Name of Drug Dosage and Frequency Route Curative Effects Side Effects
Name:Lamsen, Patrocinio
Age: 89 y/o
Sex:Female
Religion:Catholic
____________________________
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.
(
(
(
(
_________________________________
PATIENT/ RELATIVE
(Signature over printed name)
Validated:
_________________________________
STUDENT NURSE
(Signature over printed name)
_________________________________
CLINICAL INSTRUCTOR
(Signature over printed name)