Hospice Discharge Summary Form
Patient Information
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Name
First Name
Last Name
CHI Number
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Carer Name
First Name
Last Name
Details of Next of Kin
Admitted On
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Discharged On
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Admitted From
Discharged To
Follow Up Palliative Care
Main Diagnoses
Other Relevant Issues
Admission Summary
Medical Condition of the Patient
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Allergies
Current drugs and doses
Additional drugs available athome
Additional Notes
Current Care Arrangements
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Arrangements of Current Care
Awareness of Condition
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Does patient understand the diagnosis?
Yes
No
Other
Does carer understand the diagnosis?
Yes
No
Other
Does patient understand the prognosis?
Yes
No
Other
Does carer understand the prognosis?
Yes
No
Other
Advice for Out Of Hours Care
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Care Plan Agreed?
Yes
No
Other
Place of Care
Resuscitation status agreed?
Yes
No
Other
Actual resuscitation status
DNACPR form in home?
Yes
No
Other
Additional Information
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Should be Empty: