Discharge summary template and summary statement

Discharge Summary Template

Directions: Complete the Discharge Summary form by addressing the fields below.

Client Name: Date of Birth:

Date of Admission: Date of Discharge:

Presenting Problem Upon Admission:

Current Medication:

Reason for Discharge:

Case Manager Follow Up: <enter how you will follow-up with Eliza during treatment>

Resources & Referrals:

Eliza D 00/00/00		<sign and date here>
Client Signature & Date	Case Manager Signature & Date

© 2015. Grand Canyon University. All Rights Reserved.

© 2015. Grand Canyon University. All Rights Reserved.