Patient Patient Confirm If No, Confirm Allergy (Y/N) Explain Allergy (Y/N) If No, Explain 4. Pharmacy Uses hospital pharmacy? No ____ Yes ____ Community Pharmacy Phone #, Street Address, City Name Pt. plan to pick up meds upon d/c: ______________________________________________________ Pt. requests pill box? No ____ Yes ____ (Pill box ____) 5. Diet Pt. needs diet info. _____________________________ Discharge diet 6. Substance use Substance SCM Patient Report Current Tx. or Interested in Cessation Info? Alcohol Tobacco 7. Durable medical equipment needed at home?: No ____ Yes ____ If pt. checks blood sugar with glucometer, how many times daily? _______ New durable medical equipment ordered: Yes ____ No ____ Type Company name: Contact: Address: Phone: Delivery date: Type Company name: Contact: Address: Phone: Delivery date: 8. Current or New Outpatient Services (ex. VNA, PT)? ______________________________________ Service
Allergy Patient Confirm (Y/N) If No, Explain Allergy Patient Confirm (Y/N) If No, Explain 4. Pharmacy Uses hospital pharmacy? No ____ Yes ____ Community Pharmacy Name Phone #, Street Address, City Pt. plan to pick up meds upon d/c: ______________________________________________________ Pt. requests pill box? No ____ Yes ____ (Pill box ____) 5. Diet Discharge diet Pt. needs diet info. _____________________________ 6. Substance use Substance SCM Patient Report Current Tx. or Interested in Cessation Info? Alcohol Tobacco 7. Durable medical equipment needed at home?: No ____ Yes ____ If pt. checks blood sugar with glucometer, how many times daily? _______ New durable medical equipment ordered: Yes ____ No ____ Type Company name: Contact: Address: Phone: Delivery date: Type Company name: Contact: Address: Phone: Delivery date: 8. Current or New Outpatient Services (ex. VNA, PT)? ______________________________________ Service
dischargeprep.docx