Office Discharge Form

Patient's Name *

First Name Last Name

Date *

Date

Paramedic / Nurse *

First Name Last Name

Translator Name

First Name Last Name

Name of Patient Escort *

First Name Last Name

Patient Escort Phone Number

Area Code Phone Number

Signature of Patient Escort

Clear

Extubation Time

: Hour Minutes AM/PM Option

Elements that need to be put in place prior to discharge (verify that the following information is documented in the record, if applicable) *

Note reflecting readiness for discharge (modified Aldrete Score 9 or above) Discharge plan discussed with family/escort who fully understands & agrees Discharge plan discussed with Patrick McCarty, DDS All Questions of Patient / Escort Answered Pertaining to Discharge Provided Written Copy of Post Anesthesia Instructions to Escort w/ Dr. McCarty's cell phone listed

MOTORIC ACTIVITY *

	Score
Spontaneous Movement When Addressed (2)
Weak Spontaneous Movement When Addressed (1)
No Movement (0)

BREATHING *

	Score
Coughs On Command or Cries (2)
Keeps the Airway Open (1)
Obstructed Airway (0)

Blood Pressure Compared to Reference Measurement *

	Score
Change Less Than 20 mm Hg (2)
Change Equal to 20 - 50 mm Hg (1)
Change Greater Than 50 mm Hg (0)

Consciousness *

	Score
Awake (2)
Response to Stimulus, Reflexes Intact (1)
No Answer, Reflexes Absent (0)

Oxygen Saturation *

	Score
100 - 98 % (2)
97 - 95 % (1)
Less than 95% (0)

Modified Aldrete Score *

Discharge Time *

: Hour Minutes AM/PM Option