Hospital Discharge Papers – Fill Out and Use This PDF

The Hospital Discharge Papers form, specifically designed by the New York City Department of Health and Mental Hygiene's Bureau of Tuberculosis Control, is a critical document for the safe discharge of patients with infectious tuberculosis (TB). This form ensures that all necessary information, including patient contact details, discharge plans, treatment information, and follow-up appointments, is thoroughly communicated between healthcare providers and the Health Department. To ensure the well-being of the community and the patient, healthcare providers must complete and submit this form with precision and care. For more detailed instructions on filling out the form correctly, click the button below.

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Hospital Discharge Papers PDF Details

The Hospital Discharge Papers form, a comprehensive document mandated by the New York City Department of Health & Mental Hygiene, underlines the meticulous measures necessary for the discharge of patients, particularly those with infectious tuberculosis (TB). Designed to ensure public health safety and patient welfare, this form is a critical tool that health care providers must use to seek approval before discharging TB patients. The approval process, requiring submission at least 72 hours prior to the anticipated discharge date, involves a detailed review by the Department of Health, signifying the thoroughness expected in managing infectious TB cases. This document encompasses multiple sections that cover a wide range of necessary information, including patient contact details, discharge information specifying the facility and destination post-discharge, follow-up appointment details to ensure continuity of care, laboratory results that provide insights into the patient's TB status, and detailed treatment information which specifies medication regimens and any interruptions in therapy. Additionally, the form includes critical instructions for health care providers on how to complete and submit the form correctly, thus serving as a guideline for executing a responsible and safe discharge planning process for TB patients. This process not only emphasizes the significance of regulated patient discharge in preventing TB transmission but also showcases the collaborative effort between health facilities and public health authorities to uphold high standards of public health.

Question	Answer
Form Name	Hospital Discharge Papers
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	tb 354, best way to do hospital discharge planning, atlanta georgia hospital discharge papers, new york hospital discharge papers

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NEW YORK CITY DEPARTMENT OF HEALTH AND MENTAL HYGIENE

BUREAU OF TUBERCULOSIS CONTROL

HOSPITAL DISCHARGE APPROVAL REQUEST FORM

Please complete this form in entirety and fax to 347-396-7579

SECTION A: Patient Contact Information

Patient name:

DOB: _______/_______/_______

yyyy

Tel. #: (1) ( ______ )_________ – ______________

(2) ( ______ )_________ – ______________

Address:

Apt.:

City:

State:

Zip:

Emergency contact name:

Relationship to patient:

Tel. #: (

)

–

SECTION B: Discharge Information

Discharging facility:

Discharging facility tel. #: (

)

–

Address:

Fl.:

City:

State:

Zip:

Patient medical record #:

Date of admission:

Planned discharged date:

yyyy

Discharged to:

☐ Home (if not the same address as above, fill in address below)

☐ Shelter

☐ Skilled nursing facility

☐ Jail/Prison

☐ Residential facility

☐ Other facility

Name of facility:

Tel. #: (

)

–

Address:

Apt./Fl.:

City:

State:

Zip:

Is patient scheduled to travel outside of NYC?

☐ Yes ☐ No If yes, specify date/destination:

SECTION C: Patient Follow-Up Appointment

Patient follow-up appointment date:

yyyy

Physician assuming care:

Tel. #: (

)

–

Cell. #: (

)

–

Address:

City:

State:

Zip:

Potential barriers to TB therapy adherence: ☐ None

☐ Adverse reactions

☐ Homelessness

☐ Physical disability (specify)

☐ Medical condition (specify)

☐ Substance use (specify)

☐ Mental disorder (specify)

☐ Other

SECTION D: Laboratory Results

Dates of three most recent

Specimen source

Acid fast bacilli (AFB) smear results

acid fast bacilli (AFB) smears

_______/_______/_______

☐ Positive Grade: ______

☐ Negative

_______/_______/_______

☐ Positive Grade: ______

☐ Negative

_______/_______/_______

☐ Positive Grade: ______

☐ Negative

SECTION E: Treatment Information

Date TB therapy initiated:

Interruption in therapy?

☐ Yes

☐ No

If yes, state the reason and duration

yyyy

of the interruption?

☐ RIF _____ mg

☐ PZA _____ mg

☐ EMB _____ mg

☐ SM _____ mg ☐ Vitamin B6 _____ mg

TB medications

☐ INH _____ mg

at discharge:

☐ Injectables (specify)

☐ Other TB meds (specify)

Frequency: ☐ Daily ☐ 2x weekly

☐ 3x weekly

☐ Other

Was a central line (i.e. PICC) inserted on the patient?

☐ Yes ☐ No

Number of days of medications supplied to patient at discharge

Patient agreed to be on DOT? ☐ Yes

☐ No

Print name of individual filling out this form:

Date:

yyyy

Name of responsible physician at the discharging facility:

License #:

Signature of responsible physician at the discharging facility:

Tel. #: (

)

–

COMPLETED BY THE HEALTH DEPARTMENT

BTBC NUMBER:

Discharge approved: ☐ Yes

☐ No

Action required before discharge:

Reviewed by:

Date:

NAME OF HEALTH OFFICER/DESIGNEE

yyyy

TB 354 (11/10)

How to Edit Hospital Discharge Papers Online for Free

We have applied the hard work of the best developers to create the PDF editor you are going to apply. The app will assist you to fill out the tb 354 document with no trouble and don’t waste valuable time. Everything you need to do is try out the next quick rules.

Step 1: Click the orange button "Get Form Here" on the following web page.

Step 2: Now you should be within the file edit page. It's possible to add, change, highlight, check, cross, add or erase fields or words.

For every single area, fill out the data asked by the software.

atlanta georgia hospital discharge papers empty spaces to fill out

In the Address City State Zip Potential, cid Medical condition specify cid, SECTION D Laboratory Results, Dates of three most recent acid, SECTION E Treatment Information, Specimen source, Acid fast bacilli AFB smear results, cid Positive Grade cid Negative, cid Positive Grade cid Negative, cid Positive Grade cid Negative, Date TB therapy initiated, mm dd yyyy, of the interruption TB medications, cid Injectables specify cid Other, and Frequency cid Daily cid x weekly field, type in your information.

part 2 to entering details in atlanta georgia hospital discharge papers

Identify the important data in the COMPLETED BY THE HEALTH DEPARTMENT, BTBC NUMBER, Discharge approved cid Yes cid No, Reviewed by, NAME OF HEALTH OFFICERDESIGNEE, Date, and mm dd yyyy box.

atlanta georgia hospital discharge papers COMPLETED BY THE HEALTH DEPARTMENT, BTBC NUMBER, Discharge approved cid Yes cid No, Reviewed by, NAME OF HEALTH OFFICERDESIGNEE, Date, and mm dd yyyy blanks to fill out

Step 3: Choose the "Done" button. It's now possible to transfer your PDF form to your electronic device. In addition, you can send it by means of electronic mail.

Step 4: To protect yourself from any hassles as time goes on, you should make no less than two or three copies of the document.

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