DISCHARGE PLAN

Name of Client:____________________________________ Age: ________ Gender: _____________

Religion: ________________ Diagnosis: __________________________________________________
Surgery if any: _______________________________________________________________________
Hospital: _____________________________________ Room/Ward Bed No. ____________________
Attending Physician/s: ________________________________________________________________
A. OBJECTIVES
At the end of an hour of health education the client will be able to:
1.
2.
3.
4.
5.

B. METHODS
1. Medications
Name of Drug Dosage Route Curative Effects Side Instructions
(Generic and Preparation Effects
Trade Name) Frequency
Duration
Salbutamol One tab 2 mg 4x oral Bronchodilator Rapid heart
(Ventolin) a day for 7 days rate
Nausea

2. Exercise/Activity and Home Environment

Types of activity that should not be allowed

Type of Activity Allowed/To be continued: _____________________________________________

Procedure or Steps: (cite the source)
a.
b.
c.
d.
e.
Use of Equipment (if any): __________________________________________________________
Restrictions:
a.
b.
c.
 Home Environmental Hazards:
a.
b.
c.

3. Treatments/Therapies (e.g., Chest physiotherapy, warm compress, steam inhalation,

hydrotherapy, nebulization, etc)
a.
b.
c.

4. Health Teaching/Education (e.g., asthma)

Health Prevention/Promotion
a.
b.
c.
d.
e.

5. OPD Visit
Clinic Appointment Schedule: ______________________________________________________
Follow-up Diagnostic or Laboratory Exam: ____________________________________________
Referrals: _______________________________________________________________________
6. Diet
a. Prescribed Diet:________________________________________________________________

3- Day Sample Menu

Day 1 Day 2 Day 3
Breakfast Breakfast Breakfast

Lunch Lunch Lunch

Dinner Dinner Dinner

b. Diet Restrictions:
7. Spiritual Care and Psychological or Sexual Needs (Give special consideration to religious and
cultural practices)
Spiritual and Psychological Needs
( ) Spiritual Counseling
( ) Grief Work
( ) Anger Management
( ) Confession
( ) Family Therapy
( ) Reconciliation of Conflicted Relationships
( ) Supportive Counseling
( ) Join Church Organizations/Activities
( ) Prayer
( ) Meditation, Reflection, and Spiritual Devotion
( ) Religious Rituals
( ) Religious/Spiritual Materials

Sexual Needs
( ) Marriage Counseling
( ) Sex Therapy
( ) Sexual Violence
( ) Referral to Appropriate Agencies

C.DISCHARGE DETAILS
a. Date and Time of Discharge: ___________________________________________________
b. Accompanied by: _____________________________________________________________
c. Mode of Transportation: _______________________________________________________
d. General Condition upon Discharge: _____________________________________________

This discharge plan was explained to me by my student nurse and I have understood it.

_____________________________
CLIENT/SIGNIFICANT OTHER
(Signature over Printed Name)

Instructed By: Approved By:

____________________________ ________________________________
STUDENT NURSE CLINICAL INSTRUCTOR
(Signature over Printed Name) (Signature over Printed Name)

References:
1. Old format
2. https://www.scribd.com/doc/60612519/Sample-Discharge-Planning