Pulmonary Discharge Form
Please complete this form to document and communicate all necessary details for pulmonary patient discharge.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Admission Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Discharge Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Pulmonary Diagnosis
*
Summary of Hospital Course (briefly describe key events, treatments, and progress)
*
Discharge Medications (list all prescribed medications and dosages)
*
Special Instructions (e.g., activity restrictions, oxygen use, dietary advice)
Follow-Up Appointment Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Responsible Pulmonary Physician
*
Warning Signs (check all that apply and discuss with patient/caregiver)
Shortness of breath or difficulty breathing
Chest pain
Fever or chills
Increased cough or sputum
Other
Phone Number of Patient or Caregiver
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address of Patient or Caregiver
example@example.com
Patient or Caregiver Signature
*
Submit Discharge Form
Submit Discharge Form
Should be Empty: