Home Health Care Discharge Summary

Patient Information

Patient Name

Date of Birth

Patient ID

Address

Phone Number

Agency & Referral Information

Home Health Agency

Admit Date

Discharge Date

Primary Physician

Physician Phone

Diagnosis & Reason for Home Care

Primary Diagnosis

Other Diagnoses

Reason for Home Care

Summary of Care Provided

Disciplines Provided (RN, PT, OT, etc.)

Brief Description of Services

Status at Discharge

Clinical Status

Functional Status

Medications at Discharge

Discharge Instructions / Follow-up

Prepared By

Name

Title/Role

Date