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Discharge Plan

Name:________________________ Age: ____ Sex:____ Religion:_______________

Diagnosis: ___________________ __ Surgery Undergone, if any:____________________

________________________ ____________________________

Hospital: _____________________ Rm./Ward-Bed No. ___________Physician:______________

A. Objectives

B.
1. Medications (attached a separate sheet for this purpose if needed)
Name of drug Dosage and Route Curative Effects Side Effects
Frequency

2. Exercise / Activity
Type of Activity Allowed / to be continued:__________________________________
:__________________________________ __________________________________
Procedure or Steps:
_______________________________________________________________________
_______________________________________________________________________
__
Use of Equipment (if any):__________________________________________________
Restrictions:_____________________________________________________________

3. Treatment (prescribed treatment to be continued at home or to a referred health institution.)

4. Health Teachings (provide a separate sheet on specified health teachings)


( ) clinic appointments schedule ( ) use of alternative medicines
( ) follow up laboratory examinations ( ) relapse prevention measures
( ) understanding and knowing what to do with side effects of medications
( ) others __________________

5. a.. Observed signs and symptoms that need reporting:


________________________________________________________________________
________________________________________________________________________
b. Interventions / Home Remedies that may be done immediately prior to seeking
consultation:________________________________________________________________
__________________________________________________________________________

6. Diet (prescribed by the doctor / dietician).


a. Prescribed Diet:
b. Restrictions:

7. Spiritual and Psychological Needs


( ) Spiritual Counseling ( ) Confession ( ) Supportive Counseling
( ) Grief Work ( ) Family Therapy ( ) Join Organizations/ Church Activities
( ) Anger Management ( ) Reconciliation of Conflicted Relationships

A. Discharge Details
a. Date and Time of Discharge: __________________________________________________
b. Accompanied by: ___________________________________________________________
c. Mode of Transportation: ______________________________________________________
d. General Condition upon Discharge: _____________________________________________
__________________________________________________________________________
__________________________________________________________________________

THESE DISCHARGE INSTRUCTIONS WERE EXPLAINED TO THE PATIENT AND/ OR


RELATIVE

Read and Understood:

_________________________________
PATIENT/ RELATIVE
(Signature over printed name)

Validated:

_________________________________
STUDENT NURSE
(Signature over printed name)

_________________________________
CLINICAL INSTRUCTOR
(Signature over printed name)