Discharge Summary and 1 page- Documents attached to help complete.

Course: HN330

Discharge Summary Form

Client Name:

Date of Birth:

Date of Admission:

Date of Discharge:

Reason for Discharge [If the client is transferring to case management services at another agency, in addition to the Reason for Discharge, include the new agency address and new case manager name and contact information]:

Diagnosis on Admission:

Medication on date of discharge and plan for continuing prescriptions:

Presenting situation as described by client at admission to case management program:

Goals:

Progress (State goals that have been achieved as well as goals not achieved and client plan for these upon discharge):

Additional issues or concerns not documented above:

Case manager closing summary and recommendations:

I have reviewed this form with my case manager, and I understand and agree with the summary and recommendations: (Yes/No) _______

Client Initials:

Legal Guardian Initials (if one is assigned or if client is under 18):

________________________________________

I have reviewed this form with my case manager, and I wish to add the following comment to the summary and recommendations (optional):

Comment:

Client Initials:

Legal Guardian Initials (if one is assigned or if client is under 18):

Client Signature:

Date:

Legal Guardian’s Signature (if one is assigned or if client is under 18):

Date:

Case Manager Signature:

Date:

Supervisor Signature:

Date:

Copy of this completed Discharge Form received by client:

Client Initial:

Legal Guardian Initial (if one is assigned or if client is under 18):

Instructor Feedback: