DISCHARGE PLAN

Name of Client:____________________________________ Age: ________ Gender: _____________

Religion: ________________ Diagnosis: __________________________________________________
Surgery if any: _______________________________________________________________________
Hospital: _____________________________________ Room/Ward Bed No. ____________________
Attending Physician/s: ________________________________________________________________
A. OBJECTIVES
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

2. Exercise/Activity and Home Environment

Type of Activity Allowed/To be continued: _____________________________________________
Procedure or Steps:
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: _____________________________________________

I have read and understood the discharge instructions given to me.

_____________________________
CLIENT/SIGNIFICANT OTHER
(Signature over Printed Name)

Instructed By: Approved By:

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