Discharge Form
Patient's Name
*
First Name
Last Name
Date
*
-
Year
-
Month
Day
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
Extubation Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
05
10
15
20
25
30
35
40
45
50
55
Minutes
AM
PM
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
Other
MOTORIC ACTIVITY
*
Rows
Score
Spontaneous Movement When Addressed (2)
Weak Spontaneous Movement When Addressed (1)
No Movement (0)
BREATHING
*
Rows
Score
Coughs On Command or Cries (2)
Keeps the Airway Open (1)
Obstructed Airway (0)
Blood Pressure Compared to Reference Measurement
*
Rows
Score
Change Less Than 20 mm Hg (2)
Change Equal to 20 - 50 mm Hg (1)
Change Greater Than 50 mm Hg (0)
Consciousness
*
Rows
Score
Awake (2)
Response to Stimulus, Reflexes Intact (1)
No Answer, Reflexes Absent (0)
Oxygen Saturation
*
Rows
Score
100 - 98 % (2)
97 - 95 % (1)
Less than 95% (0)
Modified Aldrete Score
*
Discharge Time
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Submit
Should be Empty: