Patient Discharge Information
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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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