COVID-19 Testing Hospital Discharge Form

This form documents the discharge process for a patient treated for COVID-19, capturing diagnosis, treatment received, and the follow-up care plan.

Use this template

Page 1

Patient's I.D. #

Patient's Name

Nombre

Apellido

Attending Physician

Nombre

Apellido

Phone Number:

Date Services should end

Facility Name

Elements that need to be put in place prior to discharge (verify that the following information is documented in the record, if applicable)

Medication reconciliation completed Follow-up appointment scheduled Home care instructions provided Necessary medical equipment arranged Transportation arranged

Page 2

Salutation

Letter Introduction

a. You were admitted to (see facility above) on the following date

b. At admission you presented with the following symptoms

c. You were diagnosed with

d. You were treated with

e. Your tests were (include results)

f. You were evaluated by

g. You are now (list current treatment plan and/or state the medical issue is resolved)

h. Your provider feels that your condition has improved and that the care you need now could safely be provided in/at

i. Your discharge plan and follow-up care includes

Certification Statement

Printed name of person completing the form

Nombre

Apellido

Phone Number

Signature of person completing the form

Name

Nombre

Apellido

COVID-19 Testing Hospital Discharge Form

Page 1

Page 2

Related templates