Directions: Complete the Discharge Summary form by addressing the fields below.
Presenting Problem Upon Admission:
[State the client’s presenting problem upon admission here.]
|Client Name: [Enter the client’s name here]||Date of Birth: [MM/DD/YYYY]|
|Date of Admission: [MM/DD/YYYY]||Date of Discharge: [MM/DD/YYYY]|
[List the client’s current medications here.]
Reason for Discharge:
[State the client’s reason for discharge here.]
Resources and Referrals:
[List the client’s resources and referrals here.]
[State the client’s projected prognosis here.]
|Eliza D 00/00/00||<sign and date here>|
|Client Signature & Date||Case Manager Signature & Date|
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