Discharge Summary Form PDF Details

Most people wouldn't think of a hospital discharge summary form as something interesting, but to me it is. It's like a little piece of my life after being in the hospital for what seemed like forever. I was discharged on a Thursday night and my SummaryForm was waiting for me when I got home. It had all of the important information from my stay including the doctors' notes, medications, and lab results. It was a little snapshot into my time in the hospital and I was so grateful to have it. Now that I'm out of the hospital, I can reflect on my experience and see what worked well and what needs improvement. Overall, I am very happy with how my discharge went and I'm glad that I have the discharge summary form

QuestionAnswer
Form NameDischarge Summary Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesou discharge summary, accident discharge medical form, hospital discharge papers pdf, discharge

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Sample

Discharge Summary

Client Name:_________________________________

Date:______________________

Admitting Date:_________________

Discharge/Termination Date:_________________

Admitting Diagnosis: _____________

Discharge/Termination Diagnosis: ____________

Treatment Level Recommended: ___Short Term ___Long Term ___Day Tx ___IOP

The client successfully completed the recommended treatment program: ___ Yes ___ No

Treatment program hours completed: ________

Nature of Discharge: Tx Completed: ____ Withdrew from Tx: ____ Transfer:_______

Client Strengths/Abilities:

Presenting Concerns:

ASAM Primary Issues: 1._______________________________________________________________________

2.______________________________________________________________________

3.______________________________________________________________________

Treatment Outcome (program attendance & participation, family involvement, 12 Step attendance, achievement of treatment goals and expectation):

Updated 2/7/11

______________________________________________________________________________

Discharge Plan:

______________________________________________________________________________

Referrals:

Discharge Diagnosis:

Axis I__________________________

Axis II_________________________

Axis III_______________________

Axis IV________________________

Axis V______

Client Signature:______________________________________ Date:________________

Therapist Signature: ___________________________________ Date:________________

Updated 2/7/11

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Writing segment 1 of online discharge summary

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Part no. 2 of filling out online discharge summary

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Filling out part 3 in online discharge summary

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Discharge Plan  Referrals, Discharge Plan  Referrals, and Discharge Plan  Referrals of online discharge summary

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online discharge summary completion process described (step 5)

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