Hospital Discharge Form

Write down everything a patient needs when they leave your facility: when they arrived, the symptoms they showed, the diagnosis reached, treatments given, test results and the follow-up plan. The clinician or case manager signs it so the summary lines up with the medical record.

Use this template

Page 1

Discharge Summary

Patient's Name

Nombre

Apellido

Phone Number:

Attending Physician

Nombre

Apellido

Facility Name

Date Services should end

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

Discharge instructions handed over Medication list reconciled Follow-up appointment scheduled Home care arranged Medical equipment delivered Transport arranged Caregiver informed

Page 2

Discharge Narrative

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

Name of person completing the form

Nombre

Apellido

Phone Number

Date

Signature of person completing the form

Sign here

Related templates

Browse all reports templates →