Enter the full name of the consumer for hospital record tracking

Hospital Discharge Log Instructions:

  • Record each hospital admission and discharge for comprehensive care tracking
  • Include exact dates and times for all entries
  • Hospital staff should sign to verify admission/discharge information
  • Submit completed form within 24 hours of final discharge

Hospital Stay Record #1

MM slash DD slash YYYY
Select the date the consumer was admitted to the hospital
Time of Admission
:
Enter the time the consumer was admitted
Brief description of admission reason
Complete hospital name and address where consumer was admitted
Hospital room or unit number if available
MM slash DD slash YYYY
Select the date the consumer was discharged
Time of Discharge
:
Enter the time the consumer was discharged
Summary of discharge instructions or follow-up care
Clear Signature
Signature from hospital staff verifying admission and discharge information

Hospital Stay Record #2

MM slash DD slash YYYY
Select the date the consumer was admitted to the hospital
Time of Admission
:
Enter the time the consumer was admitted
Brief description of admission reason
Complete hospital name and address where consumer was admitted
Hospital room or unit number if available
MM slash DD slash YYYY
Select the date the consumer was discharged
Time of Discharge
:
Enter the time the consumer was discharged
Summary of discharge instructions or follow-up care
Clear Signature
Signature from hospital staff verifying admission and discharge information
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This field is for validation purposes and should be left unchanged.
This field is for validation purposes and should be left unchanged.