Long-Term Care Facility Discharge Form
Complete this form to document the discharge of a resident from the facility and ensure a smooth transition of care.
Resident Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Resident Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Discharge Date and Time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Reason for Discharge
*
Please Select
Planned discharge
Transfer to hospital
Transfer to another facility
Discharge at family's request
Other
Discharge Destination
*
Please Select
Home
Hospital
Another care facility
Other
Responsible Party for Discharge (Name & Relationship)
*
Summary of Care Provided During Stay
*
Discharge Medication & Equipment Instructions
*
Follow-Up Arrangements (Appointments, Services, etc.)
Additional Notes or Special Instructions
By signing below, I acknowledge that I have received and understand the discharge instructions and care summary provided by the facility.
*
Submit Discharge Form
Submit Discharge Form
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