D I S C H A R G E

P L A N

Name of Patient: _______________Age: ____Gender: _____Room Number: ________ Date:

____________
Time: ________________
Chief Complaints: ________________________________
Diagnosis/Impression:_______________________________________
Attending Physician: ________________________________________
MEDICATIONS
Medications
List all drugs for the patient to
be taken at home.

Dosage/Frequency
Give the full prescription
Example:

Nursing Instructions
Include patient teaching ( to
take before or after meal,
activities to avoid, signs to
watch, etc.

One tablet three times a day

Or
1 tablet 3 X a day

EXERCISE (Included step by step procedure)

THERAPY

HEALTH TEACHINGS

OPD VISITS/REFERRALS

DIET (Foods to encourage and any food restrictions, 3-day sample menu plan)

SPIRITUAL CARE (based on patients religious practices)

Ref.:___________________________________________________