discharge plan
joyokachi
DischargeTemplate1.docxI. ASSESSMENT
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Name: Click here to enter text.
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DOB: XX/XX/XXXX |
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Date of Admission: Click here to enter a date.
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Assessment Date: Click here to enter a date. |
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Admitting Diagnosis: Click here to enter text.
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Past Medical History (include surgical history) Click here to enter text. |
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Subjective history of current hospitalization (what led to current hospitalization?)
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Family and social history Click here to enter text.
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Summary of physical assessment (complete head-to-toe from hospitalization documentation) Click here to enter text.
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Allergies: Click here to enter text. |
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Effects of diagnosis on daily living: Click here to enter text. |
Current Medications (to add rows, click “insert row” on Table Layout tools)
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Name |
Dose |
Schedule |
Last taken |
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Activity of Daily Living and Instrumental Activity of Daily Living Assessment (Place an “X” in the appropriate column)
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Activity |
Not applicable |
Dependent |
Semi |
Independent |
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Bathing |
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Dressing |
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Personal Cares |
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Continence |
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Toileting |
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Transferring |
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Ambulation |
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Climbing Stairs |
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Eating |
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Shopping |
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Food Preparation |
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Managing Medications |
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Using the Phone |
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Housework |
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Laundry |
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Transportation |
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Managing Finances |
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Total |
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Patient Support System (based upon above assessment, who is available to provide care or support to patient)
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Name |
Relationship |
Availability |
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Medical Follow-up
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Financial Summary
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II. DIAGNOSIS/PLAN
List your top three priorities, create a nursing diagnosis, and create two goals for each
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Priority |
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1. Click here to enter text. |
2. Click here to enter text. |
3. Click here to enter text. |
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Nursing diagnosis |
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Client outcomes |
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1. Click here to enter text. |
1. Click here to enter text. |
1. Click here to enter text. |
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2. Click here to enter text. |
2, Click here to enter text. |
2. Click here to enter text. |
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III. EDUCATION NEEDS
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Need |
Method |
Evaluation of learning |
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I. Future Medical Care - Routine |
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Routine Care Description |
Frequency of visits |
Purpose |
Cost per visit |
Cost per year |
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IV. FINANCIAL WORKSHEET
Subtotal
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II. Future Medical Care - Specialty |
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Description |
Frequency |
Purpose |
Cost per visit |
Cost per year |
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Subtotal
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III. Future Medical Care – Treatment Interventions |
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Recommendation |
Frequency of procedure |
Purpose |
Cost per procedure |
Cost per year |
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Subtotal
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IV. Medication Needs |
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Name/dose |
Schedule |
Purpose |
Cost per month |
Cost per year |
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Subtotal
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V. Supplies |
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Supplies |
Schedule |
Purpose |
Cost per month |
Cost per year |
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Subtotal
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VI. Diagnostic Testing |
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Diagnostic Test |
Schedule |
Purpose |
Cost per month |
Cost per year |
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Subtotal
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VII. Future Adjunctive Therapies |
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Therapy |
Purpose |
Frequency |
Cost per month |
Cost per year |
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Subtotal
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VIII. Medical Equipment |
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Equipment |
Purpose |
Purchase/Rental |
Cost per month |
Cost per year |
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Subtotal
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IX. Transportation |
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Mode |
Purpose |
Purchase/PRN |
Cost per month |
Cost per year |
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Subtotal
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X. Home Furnishings and Adaptations |
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Need |
Purpose |
Initial cost |
Upkeep |
Final cost |
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Subtotal
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XI. Potential Complications |
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Complication |
Estimated Cost |
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Subtotal
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Financial Summary |
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Description |
Cost per Year |
Non-recurring cost |
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I. Future Medical Care - Routine |
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II. Future Medical Care - Specialty |
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III. Treatment Interventions |
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IV. Medication Needs |
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V. Supplies |
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VI. Diagnostic Testing |
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VII. Future Adjunctive Therapies |
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VIII. Medical Equipment |
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IX. Transportation |
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X. Home Furnishings and Adaptations |
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XI. Potential complications |
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TOTAL: |
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V. REFLECTION AND CONCLUSION
