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