DISCHARGE INSTRUCTION SHEET

Patient: __________________________________ Attending Physician: _____________________________ Ward/Rm No. __________

Medication Dose Frequency Duration

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

Diet:
_______________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________

Remarks:
________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
_

_____________________________
Attending Physician

I / We understand the importance of the above instruction and would follow these as planned and
advised.

_____________________________________________ __________________________________________
Patient/Relative Receiving Instructions Patient’s Relative / Significant Other
taking the patient Home/Transfer

_____________________________________________ ______________________________________________
Nurse Giving the Instruction Charge Nurse

DOH-SWUMed-NSD-F-024 Rev.1