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300.XXX - Discharge Instructions - Form Template

The discharge instructions summarize the patient's diagnosis, follow-up care plan, and home care instructions. The patient was instructed to follow-up with their primary care physician within a certain number of days, see a specialist if symptoms worsen or do not improve, and go to the emergency room for new or worsening symptoms. The document outlines wound care, medication instructions, and precautions depending on the diagnosis. The patient acknowledged understanding the discharge instructions and responsibility for arranging any necessary follow-up care.

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431 views1 page

300.XXX - Discharge Instructions - Form Template

The discharge instructions summarize the patient's diagnosis, follow-up care plan, and home care instructions. The patient was instructed to follow-up with their primary care physician within a certain number of days, see a specialist if symptoms worsen or do not improve, and go to the emergency room for new or worsening symptoms. The document outlines wound care, medication instructions, and precautions depending on the diagnosis. The patient acknowledged understanding the discharge instructions and responsibility for arranging any necessary follow-up care.

Uploaded by

M
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Discharge Instructions

Patient Name_________________________________ Facility _______________________________________


Date of Birth _________________________________
Date of Service _______________________________
Patient Instructions Miscellaneous Instructions / Information
Return to clinic in _____ days, earlier if worse.
See your private doctor in _____ days, earlier if worse.
See your private doctor if not improved.
Referred to:
Phone #:
Call your doctor for an appointment tomorrow. Go to the ER if new/worse symptoms occur.
Diagnosis: _____________________________________ Call __________ in _____ days for lab results.
IT IS YOUR RESPONSIBILITY TO MAKE Follow-up with PCP for lab results.
ARRANGEMENTS WITH THE APPROPRIATE PHYSICIAN
General Instructions Head Injury Precautions
Keep injured part elevated above heart for _____ hours. Report to the Emergency Room if any of the following occur:
Ice Pack 20 mins. Every 2-4 hours for the 1st 2 days.
No weight bearing. Keep splint/cast dry. Stiff neck, Fever, Dizziness, Severe or Persistent Headache,
If toes or fingers lose sensation, strength, turn cold or blue or develop Persistent vomiting (over 4 hours), Vision problems, Unusual
severe pain, loosen splint/bandage. If persists, contact physician. Behavior or confusion, slurred speech or trouble breathing.
Crutches as instructed.
Go to ER or call Dr. for new/worse symptoms. Vomiting / Diarrhea / Abdominal Pain

Wound Care __ Begin clear liquids such as water, flat Gingerale,


Suture removal in _____ days. Gatorade, Pedialyte, weak tea, or Kool-Aid.
Remove dressing in 24 hours unless otherwise directed. __ Avoid solid foods, milk, or citrus products.
Keep dressing/sutures clean and dry.
Suture wound care: After dressing has been removed, If clear liquids are tolerated, progress to apple sauce,
clean the sutured area with soap and water. Do this bananas, noodles, and soup. Regular diet may be
once a day or more often if needed. resumed if above controls the problem for 48 hours.
Place warm compresses to affected area 3 times per day. Signature of Physician / NP / PA:
Look for signs of infections such as REDNESS, SWELLING
HEAT, INCREASED PAIN, RED STREAKS, ETC.
Return if these occur.
Medication Instructions

None Prescribed No Aspirin


Tylenol / Advil for mild pain Take Medication with Food
Food and Drug Interaction TAKE MEDICATION AS INSTRUCTED.
Do not Drive, Operate Machinery, or Consume Alcohol while Taking Medication.
Note: Any medication may cause an allergic reaction. If you develop a rash, difficulty breathing or other unusual
symptoms occur after taking this medication, consult your primary care physician.
DME Equipment/Supplies Given

_______________________________________________ ______________________________________________

I hereby acknowledge receipt of the instructions indicated above and have a clear understanding of these instructions. I
understand that I may be released before all of my medical problems are known. I will arrange for my follow-up care as
instructed above. Please note: If you received a laboratory test that requires an evaluation not performed by our clinic, you
may receive a separate bill for those services by another entity.

Employee Signature Patient / Guardian Signature

Premier Health 2014

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