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COVID-19 Discharge Form

A clinical record documenting a COVID-19 patient's discharge, transfer, or death, including complications, treatments, and medications administered during hospitalization.

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Hospital ID

Type

Discharge Transfer Death

Date of Discharge/Transfer/Death

Patient Name

First Name

Last Name

Birth Date

At any time during hospitalization did the patient experience any of the following complications?

Respiratory failure Sepsis Acute kidney injury None

Was there other pathogens tested for during admission?

Influenza RSV Other None

If any, please provide further details

At any time during hospitalisation, did the patient receive/undergo any of the following treatments?

Mechanical ventilation ICU admission Antiviral therapy None

If you selected any of the above-mentioned treatments please provide further details (start and end date, duration, etc.)

While hospitalised or at discharge, were any of the following medication administered?

Antibiotics Antivirals Corticosteroids None

If and medication is administered, please provide further details (daily dosage, type, medication name, route, etc)

Ability to self-care at discharge versus before illness

Improved Unchanged Worse

Did the patient require any of the following interventions?

Oxygen therapy?

Yes No

Dialysis/renal treatment?

Yes No

Other intervention or procedure?

Yes No

Please provide further detail

Transferred Facility Name

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