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Hospital Discharge Form Template

Efficiently Manage Patient Releases with Our Discharge Template

Handling hospital discharge paperwork can be a complex and time-consuming task. This hospital discharge form template is designed to streamline the process for healthcare professionals and patients, ensuring a smooth transition from care to home. With this template, you can reduce errors in documentation, enhance patient communication, and provide clear discharge instructions, all while maintaining compliance with health regulations. Plus, it's adaptable to different healthcare settings, saving you time and effort. Explore how this template can simplify your discharge process today.

Patient full name
Date of birth
Medical record number (MRN)
Primary phone number
Preferred language for care instructions
English
Spanish
Chinese
Arabic
French
Other
Please Specify:
Emergency contact full name
Emergency contact phone number
Emergency contact relationship
Spouse/Partner
Parent/Guardian
Child
Sibling
Friend
Other
Please Specify:
Hospital or facility name
Admission date
Discharge date
Discharge destination
Home without services
Home with home health
Skilled nursing facility
Rehabilitation facility
Another hospital
Hospice
Other
Please Specify:
Primary diagnosis at discharge
Allergy or reaction details
Known allergies
No known allergies
Drug allergies
Food allergies
Latex
Environmental
Other
Please Specify:
Medication list provided to patient/caregiver
Yes
No
New or changed medications
Medications to stop
I understand how and when to take each medication
Strongly disagree
Disagree
Neither
Agree
Strongly agree
Equipment needed at home
None
Walker
Wheelchair
Cane
Commode
Hospital bed
Oxygen
Wound care supplies
Other
Please Specify:
Home health services arranged
None
Nursing
Physical therapy
Occupational therapy
Speech therapy
Social work
Palliative care
Other
Please Specify:
Transportation for discharge
Self
Family or friend
Non-emergency medical transport
Ambulance
Public transport
Other
Please Specify:
Written discharge instructions received
Yes
No
Red-flag symptoms to watch for
Please Specify:
If symptoms occur, where should care be sought
Call primary care
Call specialist
Call hospital
Call 911/emergency
Go to urgent care
Other
Please Specify:
Pain level at discharge
None
Mild
Moderate
Severe
Primary care follow-up date
Preferred contact method for follow-up
Phone call
Text message
Email
Patient portal message
Mail
Other
Please Specify:
Insurance provider
Member or policy number
Name of person who received instructions
I received and understand my discharge instructions
Strongly disagree
Disagree
Neither
Agree
Strongly agree
Typed name (serves as signature)
Date signed
I consent to share my discharge summary with listed providers
Yes
No
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Paper art illustration featuring a hospital discharge form for an article on FormCreatorAI.

When to use this form

Use this patient discharge form when a patient leaves inpatient care, observation, or the emergency department (ED). Nurses, physicians, and case managers use it to capture the diagnosis, meds, follow-ups, home care needs, and return-to-work notes in one place. It fits common scenarios: same-day surgery, pneumonia needing oxygen at home, or a weekend ER visit for chest pain. If the patient was admitted through the ER, align details with the Emergency room admission form. For tests due after discharge, add orders from the Radiology order form. The result: clear instructions for the patient and an auditable record for your team, which cuts delays, prevents readmissions, and supports safe handoffs to primary care or home health.

Must Ask Hospital Discharge Questions

  1. What is the primary diagnosis and reason for care?

    Stating the condition up front gives context for every instruction and medication. It also aligns coding and follow-up plans; if the illness is infectious, coordinate next steps using the Contact tracing form.

  2. Which medications should the patient take now, with doses, timing, and stops?

    Clear, specific medication lists prevent errors and readmissions. Listing changes from pre-admission therapy avoids duplication and harmful interactions.

  3. What follow-up appointments, labs, or imaging are needed and by when?

    Deadlines and locations help patients schedule and show up on time. Assigning responsibility (clinic schedules vs. patient schedules) increases completion and continuity of care.

  4. Which warning signs require urgent care, and whom should the patient contact after hours?

    Concrete red flags (fever, bleeding, chest pain) guide timely action and reduce risk. Listing phone numbers and escalation steps prevents confusion at night or on weekends.

  5. What activity, work, and travel restrictions apply, including return-to-work or school dates?

    Clear limits protect recovery and give employers or schools what they need. If travel is planned soon, note any requirements and reference your Travel declaration form.

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