Pre-labor patient discharge checklist form
Complete this checklist to ensure all steps are followed before patient discharge prior to labor.
Patient full name
*
First Name
Last Name
Date of discharge
*
-
Month
-
Day
Year
Date
Primary contact phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Are you experiencing any of the following symptoms? (Select all that apply)
*
Regular contractions
Vaginal bleeding
Severe pain
Fever or chills
Fluid leakage
None of the above
All prescribed medications have been reviewed and provided
*
Yes
No
Discharge instructions understood
*
Yes, I understand the instructions
No, I need further explanation
Emergency contact name and relationship
*
Emergency contact phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Follow-up appointment scheduled
*
Yes
No
Submit Checklist
Should be Empty: