Tuberculosis Discharge Planning Form
Please complete this form to support effective discharge planning after tuberculosis care.
Patient First Name or Initials
*
Discharge Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Responsible Care Coordinator
*
Contact Method for Follow-Up
*
Please Select
Phone
Email
In-person Visit
Other
Next Scheduled Follow-Up Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Key Discharge Instructions
*
Medication or Treatment Plan
*
Additional Community Resources Provided
Home Health Services
Transportation Assistance
Social Work Support
Other
Patient/Family Understanding Confirmed
*
Yes
No
Comments or Notes
Submit Discharge Plan
Should be Empty: