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Fillable Form Hospital Discharge Document

Hospital Discharge Document is used to show that patient was discharged from hospital or clinic after treatment and rest.

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What is a Hospital Discharge Document?

A HospitalDischarge Documentis a sample form only for patients who are ready to leave the clinic or hospital.

Through this form, there will be a smooth, easy process for both patients and staff.

Before discharging patients from the hospital, certain information must be on file. For this purpose, a discharge document may help to gather patient information, follow-up plan, and any other data needed for a successful discharge.

Discharge documents must be kept by hospitals or clinic safe and secure as it contains information about the patient.

How to fill out a Hospital Discharge Document?

This discharge form is simple and straightforward. It contains six (6) parts: Patient Details, Primary Healthcare Professional Details, Admission and Discharge Details, Diagnosis and Procedures, Medication Details, and Prepared by section.

Patient Details
Provide the required details of the patient.

First Name
Enter the first name of the patient.

Last Name
Enter the last name of the patient.

Middle Initial
Enter the middle initial of the patient.

Date of Birth
Enter the birth date of the patient.

Enter the age of the patient.

Enter the sex of the patient.

Enter the address of the patient.

Enter the city where the patient resides.

Enter the state where the patient resides.

Enter the zip code where the patient resides.

Primary Healthcare Professional Details
Provide the required primary healthcare professional details.

First Name
Enter the first name of the primary healthcare professional concerned.

Last Name
Enter the last name of the primary healthcare professional concerned.

Middle Initial
Enter the first name of the primary healthcare professional concerned.

Hospital/Clinic Name
Provide the name of the hospital or clinic.

Enter the address of the hospital or clinic.

Enter the city where the hospital or clinic is located.

Enter the state where the hospital or clinic is located.

Enter the zip code of where the hospital or clinic is located.

Admission and Discharge Details
Provide the required admission and discharge details.

Date of Admission
Enter the date the patient was admitted.

Source of Referal
Enter the referral source.

Method of Admission
Provide the method of admission of the patient.

Date of Discharge
Enter the date the patient was discharged.

Discharge Reason
Select the reason for discharge of patient (Treated, Transferred, Discharged Against Advice, or Patient Died). If the reason for discharge was the death of the patient, select “Patient Died” and enter the date of death on the space provided.

Diagnosis & Procedures
Provide the information on the diagnosis and procedures done to the patient on the respective spaces provided. Include the principal diagnosis in a brief manner. This will establish the main reason that is responsible for the patient’s visit to the hospital. Also, write the additional diagnosis which is the one that affects the patient’s management.

All the diagnostic and therapeutic procedures that are taken during the time of admission and discharge should be entered as well.

Medication Details
Enter all details of the medication given to the patient on discharge.

Prepared by
Enter the details of the healthcare staff that filled out the information.

Provide your signature.

Provide the date the form was filled out and signed.

Enter your name.

Job Title
Provide your job title.


This form is just a sample and may not be used for official purposes. Hospitals and clinics may use this form as a guide to customizing their own discharge paper form.


  • Requiring a discharge paper form allows the doctor to summarize the diagnosis and prescription.
  • The discharge form allows you to have a database where you can save your patient information in a centralized database and even split medical records in separate databases according to diagnosis or prescriptions. When you log all your patient data, you’ll easily find old records to help you understand your patient’s condition better.
  • Write all the required information in a brief and concise point.
  • Everything in the discharge summary is confidential and should not be accessed without the patient’s permission.
  • Make sure to record all the diagnoses and procedures accurately on the required field for this will serve as information to give to other healthcare providers in the outpatient settings. Furthermore, it is the hospital staff’s responsibility to provide this information accurately.
  • Real discharge papers have an address at the top. In making one for your facility, hospital, or clinic, do not forget to add the address or location of your facility with the state, zip code, city, and other address information.
  • For patients, filling out the hospital discharge form does not always mean that you are fully recovered.
  • For patients, medicines to be taken at home are mentioned in the form with complete details and the duration of medication.
  • Depending on the facility, hospital, or clinic, the discharge form is sometimes different from the physician’s excuse template. Ask the hospital staff regarding this.
  • There are other healthcare forms available online that you may use such as the Initial Visit Patient form, Consent form, Doctor’s Appointment form, Patient Feedback form, Client Provider’s Intake form, Patient’s Progress form, Medicine Intake form, and the like.
  • For patients, if you need more specialized care after leaving the hospital, you must receive a care plan detailing your health and social care needs. Ask the hospital staff for your care plan which includes details of the treatment and support you'll get when discharged, who will be responsible for providing support and mode of contact, when and how often support is needed, how the support will be monitored, and reviewed, name of the person coordinating the care plan, emergency contact, and information about any charges that will need to be paid.
  • If you're being discharged, make sure to coordinate with a relative or friend to collect you if needed or let the staff know if they need to make any arrangements for you.
  • For patients, you have the right to discharge yourself from the hospital or clinic at any time during your stay.

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