DISCHARGE PLANS (SUS PLANES DE ALTA)

TENTATIVE DISCHARGE DATE:

(Fecha de Alta)

RESIDENT NAME:
(Nombre de Paciente)

INSURANCE:
(Seguro)

RESIDENT ADDRESS/ LOCATION OF DISCHARGE:

(Direcion de paciente)

Telephone Number:

TRANSPORTATION:
(Transporte)

PICK UP TIME:
(Hora de recojida)
HOME HEALTH: Contact:
(Servicios de enfermeria)

Circle applicable Wound Care: Stage PEG Oxygen Trach

Item Diabetic Monitoring Hypertensive Monitoring Vent

DME: Contact:
(Equipos Medicos)

HEIGHT: WEIGHT:

SPECIAL NEEDS: Follow up with Primary Care Physician in one week after discharge
(Necesidades especiales: Una cita con su medico en una semana)

ADMISSION DATE: FAMILY NOTIFIED:

AUTH # LEVEL:
DISCHARGE PLANNER: TRANSPORT TO BILL: HMO
(Transporte de seguro)