COVID-19 Testing Hospital Discharge Form

Hospital Discharge Form
Patient's I.D. #
Patient's Name
First NameLast Name
Attending Physician
First NameLast Name
Phone Number:
Date Services should end
MonthDayYear
Date
Facility Name
Elements that need to be put in place prior to discharge (verify that the following information is documented in the record, if applicable)
Physician note reflecting readiness for dischargeDischarge plan discussed with member/familyDischarge plan discussed with attending providerDescription of discharge plan in placeTherapy notes (if applicable)Other