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Example Patient Discharge Form

A patient discharge form to be filled out for patient exit interview.






Business Network Members
  1. Henry Heckman
  2. Randall Foods International
  3. HughesTech NW, Inc
  4. MMRe, LLC






Patient Discharge Template

Word   PDF  


Patient Discharge Information


Medical Record #: _______________________

Patient Name: ________________________________________________

Location: ____________________________________________________

Physician: ___________________________________________________

Admit Date: ____/____/______

Discharge Date: ____/____/______

Patient Information:

Age: _____ DOB: ____/____/______ Gender: [__] Male [__] Female

Race:

[__] White [__] Black / African American [__] Asian [__] Hispanic [__] Native American

[__] Multiracial [__] Other________________

Diagnosis:

[__] Chest pain [__] Confirmed AMI [__] Pulmonary Edema [__] Coronary Artery Disease

[__] Unstable Angina [__] Syncope [__] Cerebral Vascular Disease

[__] Peripheral Vascular Disease [__] Other

Procedures:

[__] None [__] Cardiac Catheterization [__] PTCA [__] PTCA with stent [__] PCI

[__] Echocardiogram [__] RVG [__] ETT [__] Nuclear ETT [__] Coronary Artery Bypass Graft

Height / Weight:

Height = _______ inches Weight = _______ lbs. BMI: _______

Blood Pressure: _______/_______ mm/ Hg

Lipids, HbA1C (if diabetic):

Total Cholesterol: _______ mg/dL HDL: _______ mg/dL LDL: _______ mg/dL

Triglycerides: _______ mg/dL HbA1C: _______ mg/dL

Discharge Status:

[__] Discharge Home [__] Discharge to another hospital

[__] Discharge to skilled nursing facility

[__] Discharge to intermediate care facility [__] Discharge home health care organization

[__] Left against advice [__] Transfer to chronic or rehabilitation hospital

[__] Discharge to mental health setting [__] Discharge other [__] Expired










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