COVID-19 Patient Post-Discharge Follow-up
Patient Information
Name
Date of Birth
Patient ID / MRN
Contact Number
Follow-up Details
Date of Follow-up
Mode of Follow-up
Phone Call
Telemedicine
In-person
Follow-up by (Name/Role)
Current Symptoms
Describe current symptoms
Temperature (°C)
Oxygen Saturation (%)
Respiratory Rate (per min)
Medications & Adherence
Current medications (list)
Is the patient taking medications as prescribed?
Yes
No
Partially
Any medication issues?
Physical and Emotional Health
Mental/Emotional status
Physical activity
Other Notes / Next Steps
Other notes
Plan/Interventions/Referrals