About this template
The Hospice Discharge Summary Form is a critical clinical document used by healthcare professionals to record medical details, treatment summaries, and transition instructions when a patient is discharged from a hospital to home care or a specialized hospice facility. This structured form ensures continuity of care by capturing vital information such as main diagnoses, current medications and dosages, allergies, care plan agreements, and resuscitation statuses.
Designed for physicians, nurses, and palliative care coordinators, this template minimizes administrative friction during critical transitions. By gathering comprehensive data on patient and carer understanding of prognoses, follow-up palliative care requirements, and next of kin details, care teams can maintain accurate medical records and coordinate seamless handoffs. Transitioning this document to Doc2Form allows clinical staff to collect, organize, and securely review discharge details in Google Workspace without relying on cumbersome paper records.
Key features
- Capture complete patient demographics and emergency contact details in one structured record.
- Document primary diagnoses, secondary issues, and known patient allergies.
- Record current drug regimens, dosages, and additional home care medications.
- Track care plan agreements, resuscitation status, and DNACPR documentation.
- Seamlessly integrate submissions into Google Drive and Google Sheets for secure record-keeping.
Use cases
Transitioning hospital patients to home-based hospice or specialized …
Transitioning hospital patients to home-based hospice or specialized palliative care facilities.
Documenting end-of-life care instructions for family carers and visit…
Documenting end-of-life care instructions for family carers and visiting nurses.
Maintaining compliance records for palliative care facilities and hom…
Maintaining compliance records for palliative care facilities and home health agencies.
What this form collects
- Full Name (Short answer)Enter the patient's full legal name.
- CHI Number / Medical ID (Short answer)Enter the patient's unique healthcare identifier or medical record number.
- Email Address (Short answer)Enter the primary email address for patient or primary carer communications.
- Phone Number (Short answer)Enter the primary contact phone number.
- Residential Address (Paragraph)Enter the patient's home address or destination address.
- Carer Name and Contact Details (Paragraph)Provide the name and phone number of the primary caregiver.
- Next of Kin Details (Paragraph)Provide the name, relationship, and contact information for the next of kin.
- Admission Date (Date)Select the date the patient was admitted.
- Discharge Date (Date)Select the date of discharge.
- Admitted From (Short answer)Specify the facility or location the patient was admitted from.
- Discharged To (Multiple choice)Select the destination upon discharge.
- Main Diagnoses (Paragraph)List the primary medical diagnoses.
- Other Relevant Issues (Paragraph)Note any secondary conditions, symptoms, or relevant clinical history.
- Admission Summary (Paragraph)Provide a brief clinical summary of the hospital stay and progression.
- Allergies (Paragraph)List known drug allergies or adverse reactions.
- Current Drugs and Doses (Paragraph)Detail current medications, dosages, and administration schedules.
- Additional Drugs at Home (Paragraph)List any PRN or comfort medications prescribed for home use.
- Patient Diagnosis Understanding Status (Multiple choice)Select the patient's level of understanding regarding their diagnosis.
- Patient Prognosis Understanding Status (Multiple choice)Select the patient's level of understanding regarding their prognosis.
- Care Plan Agreement Status (Multiple choice)Indicate whether the patient and family agree with the established care plan.
- Resuscitation Status (Multiple choice)Indicate the agreed resuscitation status.
- DNACPR Form in Home Status (Multiple choice)Confirm if a physical or digital copy of the DNACPR form is present in the home.
- Follow-Up Palliative Care Arrangements (Paragraph)Describe scheduled visits from palliative nurses, hospice teams, or general practitioners.
- Additional Notes (Paragraph)Provide any extra clinical observations or special instructions.
- Supporting Document Link (Paragraph)Please paste a link to your file (Google Drive, Dropbox, etc.) or describe the document you wish to attach.
- Signature (Short answer)Type your full name to serve as an electronic signature.
FAQ
Who is responsible for completing this discharge summary?
Typically, the attending physician, case manager, or palliative nurse completes this summary upon discharging a patient from a hospital to hospice or home care.
Can I customize the fields in this Google Form template?
Yes. Once you generate the form with Doc2Form, you have full control in Google Forms to add, remove, or modify any questions to match your facility's protocols.
Where is the submitted discharge data stored?
All responses are saved directly to a secure Google Sheet linked to your form, allowing your care team to access and export records easily.
Is this form suitable for mobile devices?
Yes, Google Forms are fully responsive, enabling nurses and physicians to complete or review summaries on tablets and smartphones while on rounds.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.