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Discharge Instructions Form Template

Streamline Patient Care with Our Discharge Instructions Template

Providing clear discharge instructions can be challenging, but it's crucial for patient recovery. This template helps healthcare providers create concise, understandable discharge instructions that patients can easily follow. You'll enjoy benefits like reducing readmission rates, enhancing patient satisfaction, ensuring patients understand follow-up care, and meeting compliance standards with WCAG-aligned labels. Explore the live template to streamline your discharge process.

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Full name
Date of birth
Medical record number
Phone number
Email address
If preferred language is Other, please specify
Emergency contact name
Emergency contact phone
Preferred language
English
Spanish
Chinese
Arabic
French
Prefer not to say
Other
Please Specify:
Facility or hospital name
Admission date
Discharge date
Primary diagnosis or procedure
Allergies (include medication and other allergies)
Are isolation precautions needed at home?
Yes
No
New medications to start (name, dose, time)
Medications to stop
Updated medication schedule and doses
I understand when and how to take my medications
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I have my prescriptions or know how to get them
Yes
No
Not applicable
Wound or incision care instructions
Activity restrictions or recommendations
Diet instructions
Pain management plan (medications, non-drug methods)
Equipment or supplies needed at home (e.g., walker, dressings)
Warning signs or symptoms to watch for
Who to contact for urgent concerns (include after-hours)
If my symptoms worsen, I know what steps to take
Strongly disagree
Disagree
Neither
Agree
Strongly agree
Follow-up appointment date
Follow-up provider or clinic
Location or telehealth details for follow-up
Do you need help scheduling your follow-up?
Yes
No
Do you need transportation for your appointment?
Yes
No
Not sure
Home services arranged
Nursing
Physical therapy
Occupational therapy
Speech therapy
Respiratory therapy
Medical equipment
None
Other
Please Specify:
Primary caregiver name (if any)
Primary caregiver phone
Interpreter needed for follow-up communication
Yes
No
I understand my diagnosis and reason for hospitalization
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I understand my discharge instructions
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I feel confident managing my care at home
Strongly disagree
Disagree
Neither
Agree
Strongly agree
Teach-back: In your own words, how will you care for yourself at home?
Preferred way to receive materials
Verbal explanation
Printed handouts
Digital/online resources
Demonstration
No preference
Other
Please Specify:
I received a copy of my discharge instructions
Yes
No
Patient or guardian typed signature (enter full name)
Date signed (patient or guardian)
Staff providing instructions (name)
Staff typed signature (enter full name)
Date signed (staff)
I consent to be contacted for post-discharge follow-up
Yes
No
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Paper art illustration depicting a discharge instructions form template for FormCreatorAI article.

When to use this form

This template helps you give patients clear next steps right before they leave a hospital, clinic, or ED. Use it to summarize diagnosis, meds, wound care, activity limits, red flags, and follow-up. Nurses, physicians, and case managers benefit by standardizing instructions and reducing callbacks. Patients and caregivers leave with a plan they can follow. It also fits team workflows: attach a Hospital patient release form to finalize consent, and include a Medical requisition form for any labs or supplies patients need after discharge. If imaging is required, reference a Radiology order form so scheduling is easy. The result: fewer readmissions and safer transitions.

Must Ask Discharge Instructions Questions

  1. What condition were you treated for and why were you admitted?

    Plain language helps you and your caregiver remember the reason for care and the expected recovery. It keeps every other step tied to a clear goal.

  2. Which medications should you take, at what dose and time, and which should you stop?

    Listing exact names, doses, times, and stop dates prevents double-dosing and interactions. Adding the reason for each drug helps you take it correctly.

  3. What symptoms mean you need urgent help, and who do you contact?

    Red flags and a direct phone number reduce unnecessary ER visits and catch complications early. After-hours guidance sets expectations and speeds action when needed.

  4. What care do you need for wounds, activity, diet, or devices at home?

    Specific, doable steps improve adherence and make home care safer. Written limits prevent overexertion that can delay healing.

  5. What follow-up visits and tests are scheduled, with dates, locations, and instructions?

    Clear details reduce missed appointments and delays in care. Good documentation also supports your quality checks on a Medical record audit form.

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