(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.
Medications: Next Dose Inst. Rx
Medication Dose Route How Often
None Due Given Given
Resume all
Home Meds

Home Meds:
Returned
N/A

Interactions:
Food / Drug
Drug / Drug
Instructions Given

Nutrition: Special Diet

No Restrictions
Instructions Given Supplements/Other

Activities: Walking Exercises

No Restrictions
Instructions Given Bathing Driving
Lifting Other

Special Care: (Include Type, What to Do)

None Required Dressing(s) Drain
Instructions Given
I.V. Tube(s)
Other

Supplies/Equip.: (Include Type & How to Obtain)

None Required
Instructions Given

Referrals: Home Health Agency Phone

None Required
Resource List Equipment Supplier Phone
Other Phone

Follow-Up Care: Who When Phone

None Required
Who When Phone
Who When Phone

Comments:
None

I acknowledge receipt of the above discharge instructions. I have Patient/Significant Other demonstrates/verbalizes understanding of
received all of my belongings. discharge instructions.
Signature of Patient, Family or Significant Other Date/Time Nurse Signature/Title Date/Time

Physician’s Comments PATIENT IDENTIFICATION

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 Guidelines
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)