Home Health Care Discharge Summary
Patient Information
Patient Name
Date of Birth
Medical Record #
Address
Phone
Agency Information
Agency Name
Agency Phone
Referral/Ordering Physician
Physician Name
Physician Phone
Admission & Discharge Details
Admission Date
Discharge Date
Reason for Discharge
Diagnosis
Services Provided
Summary of Care / Course of Treatment
Status at Discharge
Discharge Instructions
Follow-Up Appointments / Referrals
Prepared By
Name
Date