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POST-VISIT DISCHARGE SUMMARY
Discharge Diagnosis
*
Required: Final diagnosis provided upon leaving the facility.
Follow-up Appointment
*
Yes
No
Is a follow-up appointment necessary?
Recommended Activity Level
*
Full
Moderate Restriction
Bed Rest
The advised physical activity level post-discharge.
New Prescriptions Issued
*
Total number of new prescriptions given.
Symptoms to Watch For
*
Fever
Severe Pain
Bleeding
Nausea/Vomiting
Swelling
Select symptoms requiring immediate medical attention.
Understanding Instructions
*
True
False
Patient confirms they understand all home-care instructions.
Date of Next Appointment
(Optional)
Optional: If known, enter the date/time for the next visit.
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