Hospital Discharge Form
Basic Information
Complete this form for all hospital discharges. Refer to Hospital Discharge Summary Form Instructions for information on how to complete this form.
Patient's I.D. #
Patient's Name
First Name Last Name
Phone Number:
Area Code Phone Number
Attending Physician
First Name Last Name
Facility Name
Date Services should end
Month Day Year
Date
Elements that need to be put in place prior to discharge (verify that the following information is documented in the record, if applicable)
Physician note reflecting readiness for discharge Discharge plan discussed with member/family Discharge plan discussed with attending provider Description of discharge plan in place Therapy notes (if applicable)

Hospital Discharge Form