Free Nursing Home Discharge Summary Template
Nursing Home Discharge Summary
This Nursing Home Discharge Summary serves as a comprehensive record of the patient's stay and care plan upon discharge. Use it to ensure continuity of care, follow-up appointments, medication management, and adherence to special instructions for optimal patient outcomes.
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Name: |
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Date of Birth: |
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Gender: |
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Admission Date: |
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Discharge Date: |
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Primary Care Physician: |
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Next of Kin/Contact: |
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Diagnosis: |
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Secondary Diagnosis: |
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Reason for Admission: |
Medical History
Summarize relevant medical history.
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Allergies: Penicillin |
Treatment and Care Received
Describe any treatment and care received (include frequency and focus areas).
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Physical Therapy: Daily sessions focusing on mobility and strength |
Functional Status
Describe the mobility status, level of assistance needed, feeding abilities, and continence status.
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ADLs (Activities of Daily Living) |
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Mobility: |
Requires walker, able to walk short distances with assistance |
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Hygiene: |
Needs assistance with bathing and dressing |
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Feeding: |
Independent, uses adaptive utensils |
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Continence: |
Incontinent, uses adult diapers |
Cognitive Status
Describe the cognitive status, including orientation and memory.
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Oriented to person and place, occasional memory lapses |
Discharge Plan
List all medications and details of any follow-up appointments.
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Medications: |
Amlodipine 10 mg daily |
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Follow-up Appointments: |
Primary Care Physician: [Month, Day, Year] |
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Home Health Care Services: |
Visiting Nurse: Twice weekly for wound care and medication management |
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Special Instructions: |
Low-sodium diet |
Recommendations/Considerations
List any recommendations or considerations for ongoing care, such as monitoring for signs of infection.
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Monitor for signs of infection at the surgical site |
Comments/Notes
Add any additional comments or notes for progress and discharge plan.
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Patient has shown significant improvement in mobility and speech |
