Hospital Discharge Papers – Fill Out and Use This PDF

Hospital Discharge Papers are a type of medical document that is used to release patients from the hospital after an overnight stay.

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Hospital Discharge Papers PDF Details

Have you ever had to fill out hospital discharge papers? If so, you know that it can be a tedious process. The good news is that there is a new form available online that can make the process easier. The bad news is that not many people are aware of it. In this blog post, we will discuss the benefits of using the hospital discharge papers form and how to access it. We will also provide some tips for completing the form accurately.

Listed below are some specifics about hospital discharge papers. It'll give you the expected time it might take you to fill in the form and several additional details.

Question	Answer
Form Name	Hospital Discharge Papers
Form Length	2 pages
Fillable?	Yes
Fillable fields	71
Avg. time to fill out	14 min 42 sec
Other names	hospital discharge paperwork pdf, nyc discharge, best way to do hospital discharge planning, pdf hospital discharge papers

12

Form Preview Example

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: _______/_______/_______

mm

dd

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:

/

/

mm

dd

yyyy

mm

dd

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:

/

/

mm

dd

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

mm

dd

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:

/

/

mm

dd

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

mm

dd

yyyy

TB 354 (11/10)

Guidelines for How to Complete and Submit the Mandatory TB

Hospital Discharge Approval Request Form (TB 354)

As of June 16, 2010, Article 11 of the New York City Health Code mandates health care providers to obtain approval from the New York City Department of Health & Mental Hygiene (DOHMH) before discharging infectious TB patients from the hospital.

Discharge of an Infectious (sputum smear positive) Tuberculosis Patient

Health care providers must submit a Hospital Discharge Approval Request Form (TB 354) at least 72 hours prior to the anticipated discharge date. The DOHMH will review the form and approve or request additional information before the patient can be discharged from the health care facility.

Weekday (non-holiday) Discharge: The written discharge plan should be submitted by fax to the Bureau of TB Control between 8am-5pm. Bureau of TB Control staff will review the discharge plan and, within 24 hours, notify the provider of approval or inform the provider of any additional information/actions required for approval prior to discharge.

Weekend and Holiday Discharge: All arrangements for discharge should be made in advance when weekend or holiday discharge is anticipated.

For detailed information about hospital admission and discharge of TB patients, please refer to the New York City Department of Health and Mental Hygiene, Bureau of TB Control Policies and Protocols manual available online at http://www.nyc.gov/html/doh/downloads/pdf/tb/tb-protocol.pdf.

Instructions for Completing the Hospital Discharge Approval Request Form (TB 354)

Section A Patient contact information: Provide the patient’s contact information including patient’s name, a verified address and telephone numbers. In addition, include a name of an emergency contact, the contact’s relationship to the patient and the contact’s verified phone number.

Section B Discharge information: Provide the name and phone number of the discharging facility, the medical record number of the patient at the facility, date the patient was admitted, planned discharge date, and the location to which the patient is being discharged. If the patient will be discharged to a location other than the patient’s address listed in Section A, a facility name (if applicable), address and phone number must be provided. If the patient plans to travel, provide the date and destination.

Section C Patient follow-up appointment: Provide the patient’s follow-up appointment date, as well as the name and contact information of the provider who is assuming patient care. Check all potential obstacles that may affect TB therapy adherence.

Section D Laboratory results: Report the results of the three most recent acid fast bacilli (AFB) smears including the date of specimen collection, specimen source, and AFB smear results and/or grade.

Section E Treatment information: Fill in the date TB treatment was initiated. If there were any treatment interruptions, indicate the reason and number of days treatment was stopped. Check the box next to each prescribed drug and state dosages for each drug. Write in drugs and dosages for drugs not specified. Specify the treatment frequency by checking one of the three boxes, or writing in a different treatment schedule. State whether the patient will have a central line inserted at the time of discharge. If TB medication will be supplied to the patient at discharge, write the number of days for which the medication will be supplied. State whether the patient agreed to be on directly observed therapy (DOT).

After Section E, the name of the person completing the form should be printed and the authorized physician at the discharging facility must print and sign their name, and provide their medical license number and telephone number.

Forms should be faxed to the DOHMH at 347-396-7579.

If you have questions about completing the form, please call 311 and ask to speak to a Bureau of Tuberculosis Control physician.

To fulfill State requirements for communicable disease reporting, health care providers must report all suspected or confirmed TB cases to the Health Department via Reporting Central (formerly Universal Reporting Form (URF)). Instructions for reporting a case of tuberculosis can be found at http://www.nyc.gov/html/doh/html/hcp/hcp-urf.shtml

NOTE: A discharge approval request form does not substitute required case reports.

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 hospital discharge forms 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.

pdf discharge form hospital empty spaces to fill out

In the Dates, of, three, mostrecent acid, fast, bacilli, AFB, smears SECTION, E, Treatment, Information Specimen, source Acid, fast, bacilli, AFB, smear, results Positive, Grade, Negative Positive, Grade, Negative Positive, Grade, Negative mm, dd, yyyy of, the, interruption Frequency, Daily, x, weekly, x, weekly, Other Date, mm, dd, yyyy and License field, type in your information.

part 2 to entering details in pdf discharge form hospital

Identify the important data in the COMPLETED, BY, THE, HEALTH, DEPARTMENT BT, BC, NUMBER Reviewed, by NAME, OF, HEALTH, OFFICER, DESIGN, EE Date, and mm, dd, yyyy box.

pdf discharge form hospital COMPLETEDBYTHEHEALTHDEPARTMENT, BTBCNUMBER, Reviewedby, NAMEOFHEALTHOFFICERDESIGNEE, Date, and mmddyyyy 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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