GUIDELINE FOR THE USE OF PATIENT DISCHARGE FORM

1. Attach patient identification label to all copies.
2. Place appropriate date in space to indicate date discharge initiated.
3. Write out patient’s medical diagnosis.
4. Write patient’s prescribed diet and check appropriate box if additional written instruction/information was provided to patient/family.
5. Write out any activity restrictions. Check appropriate box if additional information regarding restrictions was provided to patient/family.

6. Fill blank with type of referral (nursing home placement, home health care, etc.) and check box to indicate additional information was provided to patient/family. This information will most likely be provided by the social worker arranging the referral.
7. Place name of patient's physician at time of discharge.
8. Write out all prescribed medications, including dose with time (Pepcid 20mg 2 times a day).
9. Write out any specific instructions for the patient. Preprinted discharge instructions/information sheets, MedTeach sheets, etc. should be attached and listed in this area.

KEYPOINT: State all information in layman's terms to assist in patient understanding.

10. List clinic appointments or procedure appointments that the patient is required to schedule, including the reason for the procedure and time frame for appointment.
11. List clinic appointments that have been scheduled for the patient, including date and time. Provide a UAMS map, if needed.
12. Write in date and time of discharge.
13. Place signature of discharging nurse.
14. Write in where patient is being discharged to and mode of transportation to front door of hospital.
15. Place signature of patient/family following discharge instructions.
16. Give original, white copy of form to the patient/family, yellow to chart and pink copy to follow-up clinic.

RESOURCE PERSON: Betty Casali, RN, CSM