DISCHARGE INSTRUCTIONS

[Hospital name and department or unit]
[Phone for questions about this stay, and its hours]

Name: [Patient's full name]
Date of birth: [Date]
You came in on: [Date, and whether through the emergency department]
You went home on: [Date and time]
Looked after by: [Doctor or nurse practitioner, and the nurse who went over these instructions]
Going home to: [Home alone, home with family, or home with nursing visits]
Language: [Language of these instructions, and the interpreter used, or none]

WHAT HAPPENED IN HOSPITAL
Main problem: [What you were treated for, in everyday words, then the medical name]
What we did: [The main tests, treatments, or procedures, a sentence or two each]
How you are now: [What is better, and what will take longer to settle]

YOUR MEDICINES FROM TODAY
Start: [New medicine, what it is for, how much, how often, and the last day if it is a short course]
Change: [Medicine, the dose you took before, and the dose from now on]
Stop: [Medicine, and the reason, so you don't start it again]
Same as before: [Your usual medicines that did not change]
Last dose given here: [Each medicine given before you left, and the time]
Next dose due: [Each medicine, and the time to take it at home]
Prescriptions: [The pharmacy they were sent to, or printed, and how many days they last]

LOOKING AFTER YOURSELF AT HOME
Activity: [What you can do now, what to avoid, and until when]
Driving: [When you can drive again, and why not yet]
Work or school: [When you can go back, and whether a note was given]
Eating and drinking: [Any changes, or eat and drink as usual]
Cast, wound, drain, or device: [How to keep it clean and dry, what normal looks like, and when it comes off]
Bathing: [When you can shower or bathe]

WARNING SIGNS
Call [the clinic, the unit, or your family doctor] within 24 hours if: [Signs that need advice soon]
Come back to the emergency department now if: [Signs that can't wait for an appointment]
Call 911 if: [Signs of a life-threatening problem]

APPOINTMENTS AND RESULTS
Booked for you: [Clinic or clinician, date, time, and place]
You need to book: [Who to call, the number, and by when]
Referrals: [The service we referred you to, why, and when they will contact you, or none]
Results still to come: [Each test, who will check it, and how you will hear]
If you haven't heard by: [Date, and the number to call]

WHO TO CALL
Questions about this stay: [Unit or department phone, and its hours]
After hours: [Nurse line, or the emergency department]
Your family doctor: [Name and phone, and whether a copy of your discharge summary was sent, or who follows up if you have none]

BEFORE YOU LEAVE
Gone over by: [Name and role, and who else was there]
You told us back: [The key points the patient explained in their own words]
Given to you: [Printed instructions, leaflets, equipment, or supplies]
Signed: [Patient or caregiver, or spoken agreement and who witnessed it]