HMH Discharge Checklist
Name
First Name
Last Name
Patient No:
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Discharge Summary
Instructions for care
General Checklist
Rows
Yes
No
Not Applicable
Service Quality Assessment Questionnaire Completed?
Prescription has been filled?
Has the managing Consultant been informed about discharge?
Patient's personal belongings have been gathered?
Follow up appointment has been booked?
Dietary restrictions noted?
Wound care instructions given?
Pain management plan given?
Has the patient been discharged with any specimen?
Please Select
Yes
No
If yes, then please specify
Patient/Parent/Guardian
First Name
Last Name
Signature
Medical Officer/Consultant
First Name
Last Name
Signature
Submit
Submit
Should be Empty: