Central Line Catheter Discharge Instructions Form
Please complete this form to confirm understanding and receipt of central line catheter discharge instructions.
Patient Full Name
*
First Name
Last Name
Date of Discharge
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Catheter Type and Location
*
Name and Role of Person Completing Form
*
Key Home-Care Instructions Reviewed and Understood
*
Keep catheter site clean and dry
Wash hands before touching catheter
Flush catheter as instructed
Do not remove dressing unless instructed
Signs and Symptoms Reviewed
*
Redness or swelling at site
Fever or chills
Pain or drainage at catheter site
Catheter not working or damaged
Emergency Contact Name and Phone Number
*
Follow-Up Appointment Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Acknowledgment of Instructions Received
*
Yes, I have received and understand the discharge instructions
No, I need further explanation
Submit
Should be Empty: