Respiratory Care Unit Discharge Form
Complete this form to document patient discharge from the Respiratory Care Unit, ensuring all necessary clinical and follow-up details are recorded.
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Medical Record Number
*
Admission Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Discharge Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Primary Diagnosis at Admission
*
Clinical Status at Discharge (select all that apply)
*
Stable
Improved
Requires Oxygen Therapy
Requires Non-Invasive Ventilation
Requires Tracheostomy Care
Needs Home Respiratory Equipment
Other
Medications at Discharge (list all prescribed)
*
Discharge Instructions (check all that apply)
*
Continue Oxygen Therapy at Home
Pulmonary Rehabilitation Referral
Inhaler/Device Training Provided
Follow-Up Appointment Scheduled
Home Nursing Referral
Other
Follow-Up Appointment Date (if scheduled)
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Responsible Healthcare Provider Name
*
First Name
Last Name
Contact Number for Questions/Concerns
*
Please enter a valid phone number.
Format: (000) 000-0000.
Submit Discharge
Should be Empty: