Discharge Form
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Discharge Form (PDF, 90 KB)
Instructions: Use the following information to complete the discharge form.
Mrs. Lottie Hanvers, a 48 y/o patient was admitted to Davis Hospital on May 12, 2017 after falling at home and sustaining a mild concussion and broken left pinkie finger. During the hospitalization, she was diagnosed with type II diabetes and was put on an oral hypoglycemic medication. She also took Tylenol for pain. She had taken no medications prior except for acetaminophen for pain but occasionally, and has no allergies. She was hospitalized for two days and, during that time, the hospital nutritionist provided instructions on a diabetic diet and the RN showed her how to use the blood glucose meter. She is now being discharged to her home.
Mrs. Hanvers lives at 235 W. Oak Avenue in Chicago, IL 60505. Her phone number is 312-555-5555. Her emergency contact is Joan Allers, her best friend from church. Joan’s phone number is 512-999-0000. She has been receiving treatment at Davis Hospital, which is located at 440 Wabash Street in Chicago, IL 60505. The phone number of the hospital is 312-456-789.
The physician responsible for Mrs. Hanvers is Dr. Andrews, her primary care physician. Dr. Andrews has scheduled a follow-up appointment for Mrs. Hanvers with Dr. Janis, an endocrinologist, in three days. Dr. Janis also practices at Davis Hospital.