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COVID-19 Testing Hospital Discharge Form Template

Streamline patient tracking after COVID-19 hospital discharge

Managing the discharge process for COVID-19 patients can be overwhelming, but a structured approach helps ease this burden. This template supports hospitals in tracking patient status following COVID-19 treatment, ensuring they receive necessary follow-up care and guidance. With this form, you can document vaccination status, record essential health data, streamline communication between healthcare providers, and promote patient safety. Start using this template to enhance your hospital's discharge workflow today.

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Full legal name
Date of birth
Phone number
Email address
Medical record number or patient ID
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Date of visit/test
Test type performed
PCR/NAAT
Rapid antigen
Not sure
Other
Please Specify:
COVID-19 test result
Positive
Negative
Inconclusive
Pending
Not tested
Symptom status at discharge
Asymptomatic
Mild symptoms
Moderate symptoms
Symptoms resolved
Prefer not to say
I received written and verbal discharge instructions
Yes
No
Living situation for isolation
Live alone
Live with others and can isolate
Shared housing; cannot isolate effectively
No stable housing
Prefer not to say
High-risk medical conditions (check all that apply)
Are you currently taking medications that weaken your immune system?
Yes
No
Not sure
Prefer not to say
Support needed during isolation or recovery (check all that apply)
Food delivery
Medication delivery
Transportation to follow-up
Housing or isolation support
Access to primary care
Employer or school documentation
None of the above
Do you require an interpreter for follow-up?
Yes
No
Preferred follow-up contact method
Phone call
Text message
Email
No follow-up needed
Prefer not to say
Primary care provider name and contact (if applicable)
Permission to share your test result with your primary care provider
Yes
No
I do not have a primary care provider
Patient signature (type full name)
Signature date
Discharging clinician name
Clinician signature date
I confirm the information provided is accurate to the best of my knowledge
Yes
No
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When to use this form

Use this template when you discharge a patient who was tested for COVID-19 in the ED, inpatient unit, or pre-op clinic. It standardizes instructions, records the test result or pending status, and confirms isolation and follow-up needs. Nurses, discharge planners, and infection prevention teams save time, while patients and caregivers leave with clear next steps. Pull prior results with a Medical record request form. If symptoms worsen after discharge, you can fast-track a return using the Hospital admission form. Scenarios include sending home a stable positive case, discharging a negative patient, or releasing a pending test with safe isolation and callback plans.

Must Ask COVID-19 Testing Hospital Discharge Questions

  1. What is your most recent COVID-19 test date, type, and result?

    This sets isolation timeframes and return-to-work guidance, and confirms if results are pending. Accurate details prevent conflicting instructions and support timely contact notifications.

  2. Do you currently have symptoms, and when did each symptom start or resolve?

    Symptom timing relates to contagiousness and shows if you are safe to recover at home. It also flags warning signs that require longer observation or oxygen support.

  3. Do you have a safe place to isolate at home, needed supplies, and support for daily care?

    Home setup affects transmission risk and readmission rates. If you lack space, supplies, or help, the team can arrange alternatives or community resources.

  4. Which follow-up visit or repeat testing is scheduled, and on what dates and locations?

    Knowing this helps coordinate care and avoid missed labs. If a new swab is needed, initiating a Medical requisition form at discharge speeds turnaround.

  5. Do you need documents for work, school, or travel, and do you consent to share your results?

    This ensures you leave with the right paperwork and that releases follow privacy rules. For employer or school attestations, pair your discharge summary with a Health declaration form.

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