Heart Failure Discharge Instructions (Page 2 of 2) in pdf

Heart Failure Discharge Instructions Page 2

HEART FAILURE – CONGESTIVE HEART FAILURE

DISCHARGE INSTRUCTIONS: GUIDELINES TO FOLLOW AT HOME

Page 2 of 2

FOLLOW‐UP APPOINTMENTS/OUTPATIENT SERVICES:

•

Unless an appointment has already been made, contact your Primary Care Physician’s office to schedule a follow‐up

appointment.

Doctor Date/Time

Test/Procedure Date/Time

Other Date/Time

Follow‐Up Echocardiogram

REFERRAL TO SOCIAL WORK AGENCY?

Yes No If yes, which agency? ________________________________________________________________________

________________________________________________________________________

This form is not all inclusive. Your physician may give

you additional instructions. Should you have any

questions, please contact your physician. Please bring

this discharge instruction form and the discharge

________________________________

_________________

PHYSICIAN SIGNATURE (OPTIONAL)

DATE

medication list to your next physician appointment.

I have read and understand my plan of discharge.

_____________________________

_________________

______________________________________ ______________

NURSE SIGNATURE

DATE

SIGNATURE OF PATIENT OR SIGNIFICANT OTHER DATE

CHF DISCHARGE INSTRUCTIONS

PATIENT LABEL

FORM # 536 CHF

FORMULATED: 10/01/04

REVIEWED: 5/06,8/06

REVISED: 8/06,3/08,10/08

WHITE: CHART

YELLOW PATIENT

December 9, 2008

PINK: PHYSICIAN

H:\ClinicalPathways\CHF\HeartFailureCHFDischIns

Heart Failure Discharge Instructions Page 2