DE LA SALLE LIPA

COLLEGE OF NURSING
1962 J.P. Laurel National Highway, Lipa City
Tel. (043)756-5555, 756-2491, 756-2391 loc 270

SCHOOL OF NURSING

DISCHARGE ASSESSMENT AND SUMMARY FORM

Date of Discharge Time of Discharge Mode of Discharge Accompanied by:

December 15, 2010 7:45PM Wheel Chair Nurse on Duty

Belongings sent with Personal medications sent with Prescription sent with Temp Pulse Resp BP
patient or family patient or family patient

36.8° 88 23 110/70
YES NO YES NO YES NO C

Discharge Destination: Transfer Info Sent

HOME HAMA ABSCONDED TRANSFERRED YES NO

PATIENT ASSESSMENT AND HEALTH STATUS

 Afebrile Hygiene:  Skin intact

 Able to live independently Self-care  Eating well
Pain controlled Assist  Adequate hydration
 Oriented  Total care
 Appropriate behavior  Adequate elimination
 Functions independently

INSTRUCTIONS

Diet: Activity: Special Equipment/Treatment

Full Diet Exercise daily, encourage ambulation, prevent None

doing hard choirs and prevent carrying heavy
objects.

Discharge Medications (Drug, Dosage, Special Instruction)

Cefalexin 500 ml, 50 ml, TID (8am,12 pm and 6pm).

Special Instructions/Discharge Summary

Increase Oral Fluid Intake

Physician Follow Up Appointment / Out Patient Visit Referral

None N/A

I have received a copy and understand the above instructions.

Signature of Responsible Party: Father Date: December 15, 2010

Nurse Signature: Inhumang, Nico john A. Date: December 15, 2010