UNIVERSITY OF SAN CARLOS

COLLEGE OF NURSING

Discharge Plan

Name:________________________ Age: ____ Sex:____ Religion:______________________

Diagnosis: ________________________ Surgery Undergone, if any:____________________
Hospital: _________________ Rm./Ward-Bed No.__________Physician:_________________

A. Objectives

B. 1. Medications (attached a separate sheet for this purpose if needed)

Name of Drug Dosage and Route Curative Side Effects

Frequency Effects

2. Exercise / Activity
Type of Activity Allowed / to be continued:_______________________________
_________________________________________________________________

Procedure or Steps:_________________________________________________
_________________________________________________________________

Use of Equipment (if any):____________________________________________

Restrictions:_______________________________________________________
_________________________________________________________________
_________________________________________________________________

3. Treatment (prescribed treatment to be continued at home or to a referred health

institution.)
4. Health Teachings (provide a separate sheet on specified health teachings)
( ) clinic appointments schedule ( ) use of alternative medicines
( ) follow up laboratory examinations ( ) relapse prevention measures
( ) understanding and knowing what to do with side effects of medications
( ) others:

5. a.Observed signs and symptoms that need reporting:

__________________________________________________________________________
__________________________________________________________________________

b. Interventions / Home Remedies that may be done immediately prior to seeking

consultation:________________________________________________________________

6. Diet (prescribed by the doctor / dietician).

a. Prescribed Diet:
b. Restrictions:

7. Spiritual and Psychological Needs

( ) Spiritual Counseling ( ) Confession ( ) Supportive Counseling
( ) Grief Work ( ) Family Therapy ( ) Join Organizations/ Church
Activities
( ) Anger Management ( ) Reconciliation of Conflicted Relationships

A. Discharge Details
a. Date and Time of Discharge: __________________________________________________
b. Accompanied by: ___________________________________________________________
c. Mode of Transportation: ______________________________________________________
d. General Condition upon Discharge:______________________________________________
____________________________________________________________________________
____________________________________________________________________________

THESE DISCHARGE INSTRUCTIONS WERE EXPLAINED TO THE PATIENT AND/ OR

RELATIVE

Read and Understood:

_________________________________
PATIENT/ RELATIVE
(Signature over printed name)

Validated:

_________________________________
STUDENT NURSE
(Signature over printed name)

_________________________________
CLINICAL INSTRUCTOR
(Signature over printed name)