Medication Plan and Discharge Summary
Medication Plan and Discharge Summary
Medication Plan and Discharge Summary
Revised Add Date. File in Medical Record as part of Discharge Documentation package
Form MR
Organisation logo here
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Reports and Results (þ Tick box & including number of pages for each item):
Pathology Results [Circle included items: Biochemistry / Haemotology / Drug levels] No. Pages ___
Other or Comment: ______________________________________________________________________
Radiology Reports [Circle included items – X-Ray / CT Scan / Ultrasound] No. Pages ____
"Important: This transmission is intended only for the use of the addressee and may contain
confidential or legally privileged information. If you are not the intended recipient, you are notified
that any use or dissemination of this communication is strictly prohibited. If you receive this
transmission in error please notify the author immediately and delete all copies of this
transmission."
Revised Add date. File in Medical Record as part of Discharge Documentation package Form MR
DISCHARGE FOLLOW
UP Affix Patient Information Label HERE
CONSENT
I hereby authorise the Discharge Nurse of (Organisation's name) to contact my Health Care
Professional (GP, Psychiatrist, and/or Case Manager) to provide health information related to my
Address: ______________________________________________________________________
Email: _________________________________________________________________________
If you do not consent to any of the statements, cross out that statement.
This consent form is valid for a period of 12 months from the date of this form being signed.
HIM Revised Add date . File in Medical Record as part of Discharge Documentation package MRN
PSYCHIATRIST’S
DISCHARGE
SUMMARY Affix patient information label here
Signature: _______________________________________________
Date: ______/______/____________
MRM Revised Add date: Copy faxed to patient’s referring community practitioner (GP or other) File in Medical Record Form MR
HOSPITAL
DISCHARGE Affix Patient Information Label HERE
SUMMARY
Instructions - Medical Officer to complete pages 1 and 2 (Medications); Pharmacy page 2 (sign/date);
Nursing staff to complete page 2 Community pharmacy and Webster pack details, and page 3 - com-
plete all sections prior to faxing within 12hrs to 48hrs of patient discharge.
2. __________________________________________________________________________________________________________
3. __________________________________________________________________________________________________________
New Physical findings and Test results (Reports attached Tick box if relevant)
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Medical follow-up required (For example: Urgency of GP follow-up, repeat tests, Non-psych Specialist management required, etc.)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Alerts ( □No Alerts □Suicide - history □Self-Harm □Substance abuse □Falls risk
all relevant items)
MR Revised Add date Copy faxed to patient’s referring community practitioner (GP or other) File in Medical Record Page 1 of 3 Form MR
BINDING MARGIN — DO NOT WRITE
PRN PRN
Medical Officer’s
signature : _____________________________________________Date:______________________Print name: ___________________________________________VMO or Registrar or CMO
Patient has consented to community pharmacy contact? Yes / No / Not documented Patient had a Webster pack on admission or Webster pack requested for discharge
(circle response) (circle response)
Revised Nov. 2008 Copy given to patient; Copy faxed to patient’s referring community practitioner (GP ± other); File in Medical Record page 2 of 3
HOSPITAL DISCHARGE SUMMARY - MEDICATIONS
Preferred language:
Interpreter ( relevant item) □ Required □ Not Required
Health of the Nation Outcome Scales (HoNOS) total score on: Admission _______ Discharge: _______ N/A
Edinburgh PND scale: On Admission: _________ On Discharge: ________ N/A
Summary Social Issues ( all relevant items—complete details if required) □ No Social Issues identified
□ ACAT Assessment - date: / / □ Centrelink □Pastoral Care Support
□ Dept. of Housing □ Other (specify) ________________________________
BINDING MARGIN — DO NOT WRITE
Comment(s) _______________________________________________________________________________________
Discharge Goals (Refer to patients discharge planning book and write one Short term and Long term goal)
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Follow-up appointments confirmed (Psychiatrist, GP, ECT, Counselling or Therapy Programme, Psychologist, D/C nurse, etc.)
I have read and understood this discharge summary and I have received my Future plan (i.e. information pack ).
Patient’s signature:____________________________________ or Carer signature:________________________________
Caregiver’s Signature: ______________________________________ Date: ______________________________
Caregiver print first name: ________________________________________Designation: ____________________(e.g. Nurse)
This section to be completed by the person responsible for ensuring the completed Hospital Interim Discharge Summary (HIDS)
is sent to the patient’s Referring practitioner
Copies also sent to the patient’s: □GP □Psychologist □CMHT □Psychiatrist
□Other (specify):_______________________________________________________________________________
Revised Add date: Copy given to patient; Fax to Patient’s Referring Community Practitioner (GP, Other) on Discharge. File in Medical Record Page 3 of 3