(To delete this text box, click its border to select it and then press DELETE.


This template is provided to you by Standard Register. They are the creators and owners of this template and are solely responsible for the quality and accuracy of its content.
None Resume all Home Meds




How Often

Next Dose Due

Inst. Given

Rx Given

Home Meds:
Returned N/A

Food / Drug Drug / Drug Instructions Given

No Restrictions Instructions Given

Special Diet Supplements/Other Walking Bathing Lifting Exercises Driving Other

No Restrictions Instructions Given

Special Care:
None Required Instructions Given

(Include Type, What to Do) Dressing(s) I.V. Other Drain Tube(s)

None Required Instructions Given

(Include Type & How to Obtain)

None Required Resource List

Home Health Agency Equipment Supplier Other

Phone Phone Phone When When When Phone Phone Phone

Follow-Up Care:
None Required

Who Who Who


I acknowledge receipt of the above discharge instructions. I have received all of my belongings. Signature of Patient, Family or Significant Other Date/Time Physician’s Comments

Patient/Significant Other demonstrates/verbalizes understanding of discharge instructions. Nurse Signature/Title Date/Time

Physician’s Signature It has been a pleasure to care for you. If you have any problems or questions contact your physician. Phone:

Patient Discharge Instructions
N5405 Rev. (12/31/2003)

Patient Discharge Instructions Form #N5405
Procedure: • • • • Check appropriate boxes applicable to patient. Date and time is per facility policy – Military vs. Standard. Charting is done at the time of each discipline’s visit.


Medication Section: List all medications the patient is discharged on. Fill in appropriate dose, route, how often and next dose due. Indicate if instruction and prescription was given to the patient. Nutrition Section: List diet and any supplement if applicable for patient. Activity Section: Outline any specific restrictions required of patient. Special Care Section: List type of special care items and what to do. Supply/Equipment Section: List any necessary equipment and how they are to obtain the equipment. List agency and phone numbers where equipment is obtained. Referral Section: Indicate referrals and list agency and phone number for reference. Indicate if resource list given to patient. Follow-Up Care Section: Indicate if follow-up is not required or if applicable, list whom follow-up appointment is with, when and phone number. Comment Section: Indicate further instructions needed for patient education at time of discharge. Patient, Family or Significant Other Acknowledgement: This signature indicates receipt of discharge instructions, belongings, and list of available ambulances. Nurse Signature: Nurse’s signature indicates that patient, family or significant other demonstrated/verbalized understanding of discharge instructions. Physician Comments/Signature: Physician’s signature indicates approval of discharge instructions. Patient Identification Area: Stamp with the patient’s addressograph plate. Because this form is intended for use at several facilities, the addressograph should include facility identification information in addition to patient information.

• • • • • • • • • • •

N5405 Rev. (12/31/2003)