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Example Patient Discharge Form

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

Patient Discharge Template

Patient Discharge Information

Medical Record #:


Patient Name:






Admit Date: ____/____/______

Discharge Date: ____/____/______

Patient Information:

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


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


[__] Chest pain [__] Confirmed AMI [__] Pulmonary Edema [__] Coronary Artery Disease [__] Unstable Angina [__] Syncope [__] Cerebral Vascular Disease [__] Peripheral Vascular Disease [__] Other


[__] 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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