Document for discharge from hospital other than emergency room.
Sample

Name of the patient:	First and last name of patient
Date of birth of the patient:	March 22, 1967
Consciousness:	Able to answer relevant questions correctly
Pulse Rate:	78
Blood Pressure:	122/80
Temperature:	98.3°F oral temperature
Height:	70.60 inches
Weight:	176 lbs.
Body mass index:	24.99
Problem list:	Upper respiratory infection, stress
Visit date:	January 10, 2016
Visit location:	5042 N. Winthrop Ave. #237, Chicago, Illinois 60640
Visit provider:	Asif Qrueshi, MD At this point, Doctor Asif Qureshi does not see the patient in person/face to face. Doctor Asif Qureshi guides existing physicians, medical students, and the public through the Internet guidelines. Further guidelines can be found at http://www.qureshiuniversity.com/healthcareworld.html These types of guidelines are more effective.
Follow-up recommendations:	Return to the clinic if symptoms persist.
Your care plan and instructions:	Instructions were discussed during the visit.
You current allergy list:	No known allergies
Test results from past 3 days:	None
Orders from today’s visit:	No current orders
You self-management goals:	What best describes your self-management goals? Self-management goals put in writing. No current self-management goals.
Your current medication list:	600 mg of Ibuprofen, 1 by mouth every 6 hours as needed. 500 mg of Amoxicillin, 1 by mouth 3 times a day
Pharmacy:	For example, Osco Pharmacy, 5343 North Broadway, Chicago, Illinois 60640 Telephone: (773) 784-1922

When will the patient be discharged? ----------------------------------- How often should there be follow-up? ----------------------------------- What is the advice on discharge? -----------------------------------