University of San Carlos

School of Health Care Professions

Department of Nursing

DISCHARGE PLAN FORMAT

(Revised 2021)

A. PATIENT INFORMATION:

Name: __________ Age: __________ Sex: □Male Religion: __________

□ Female
Hospital: ______________________________________
Attending Physician: _____________________________
Diagnosis: _____________________________________

B. OBJECTIVES
1.
2.
3.

C. i. MEDICATION INSTRUCTIONS (Attached a separate sheet for this purpose, if needed)

● Note: This section refers to the take home medications of the patient.

Name of Drug Dosage Frequency Route Indication Side Effects

(Note: write (Note: exact (Note: need (Note: by
the generic & dosage and to write the mouth,
brand name.) how many exact time to sublingual,
tablets are administer injection [IM,
to be taken the drug) SC], topical,
by the or rectal)
patient)

10 mg tab; 1 By mouth
rosuvastatin tab Hours of To lower Lightheadedness
(Crestor) sleep: 8pm cholesterol
level
100 mcg; 1 By mouth
levothyroxine tab Before It replaces or Headache,
(Euthyrox) breakfast provides hyperactivity,
thyroid anxiety
hormone
ii. EXERCISE/ACTIVITY INSTRUCTIONS
o Type of Activity allowed/to be continued

o Procedure or Steps

o Use of Equipment (if any)

o Restrictions:

iii. TREATMENT INSTRUCTIONS (IF APPLICABLE)

Example: wound care/dressing, colostomy care, NGT/Gastrostomy feeding at home

iv. HOME REMEDIES

● OBSERVED signs and symptoms

● INTERVENTIONS that may be done immediately prior to seeking

v. OUT-PATIENT REFERRAL
Example: For follow-up check up with Dr. Patalinghug on Jan. 31, 2020 with TSH result.

vi. DIET INSTRUCTIONS

● Prescribed diet

● Restrictions
Example: Prescribed diet: low salt, low fat diet
Instruct the patient to avoid canned meat, or fish, processed meat like corned beef

vii. SPIRITUAL AND PSYCHOLOGICAL INSTRUCTIONS

□ Spiritual counseling
□ Confession
□ Supportive counseling
□ Grief work
□ Family therapy
□ Join organization/church activities
□ Anger management
□ Reconciliation of conflicted relationships
□ Others __________
 D. DISCHARGE DETAILS
a. Date and time of discharge:
b. Accompanied by:
c. Mode of transportation:
d. General condition upon discharge:

EXPLAINED IN ENGLISH AND/OR IN DIALECT, THESE DISCHARGE INSTRUCTIONS WERE READ AND
UNDERSTOOD BY THE PATIENT, FAMILY, AND/OR RELATIVE.

_________________________ ________________________
PATIENT/RELATIVE STUDENT NURSE
(Signature over Printed name) (Signature over Printed name)

________________________
CLINICAL INSTRUCTOR
(Signature over Printed Name)