University of San Carlos

College of Nursing
Cebu City

DISCHARGE PLAN

Name: Age: Sex: Religion:

Diagnosis: Surgery undergone, if any:
Hospital: Physician:
Rm/Ward-Bed No.:

A. OBJECTIVES
1.
2.
3.
4.

B.
1. MEDICATIONS

Name of Drug Dosage & Frequency Route Curative Effects Side Effects

2. EXERCISE / ACTIVITY
Type of Activity allowed / to be continued:

Procedure or Steps:

Use of Equipment (if any):

Restrictions:

3. TREATMENT
4. HEALTH TEACHINGS
( ) clinic appointment schedules ( ) use of alternative medicines
( ) follow-up laboratory examinations ( ) relapse prevention measures
( ) understanding and knowing what to do with side effects of medications
( ) Others:

5. a. Observed signs & symptoms that need reporting:

b. Interventions / Home remedies that may be done immediately prior to seeking

consultation:

6. DIET
a. Prescribed Diet:

b. Restrictions:

7. SPIRITUAL AND PSYCHOLOGICAL NEEDS

( ) spiritual counseling ( ) confession ( ) supportive counseling
( ) grief work ( ) family therapy ( ) join organizations/church activities
( ) anger management ( ) reconciliation of conflicted relationships

C. DISCHARGE DETAILS
a. Date and Time of Discharge:
b. Accompanied by:
c. Mode of Transportation:
d. General Condition upon Discharge:

THESE DISCHARGE INSTRUCTIONS WERE EXPLAINED TO THE PATIENT

AND/OR RELATIVE

Read and Understood:

_____________________________________
PATIENT / RELATIVE
(Signature over printed name)

Validated:

_____________________________________
STUDENT NURSE
(Signature over printed name)

_____________________________________
CLINICAL INSTRUCTOR
(Signature over printed name)