Discharge Instructions

1. Patient's Name: ____________________________________
2. Diagnosis: Your child's diagnosis is ____________________________
3. Discharge Instructions:
   • For pain or fever over 102°F (39°C) give:

     ____ mg of acetaminophen every 4 to 6 hours OR

     ____ mg of ibuprofen every 6 to 8 hours

   • ______________________________________________________________
   • ______________________________________________________________
4. Additional Instructions:
   • _______________________________________________________
   • _______________________________________________________
   • _______________________________________________________
5. Follow-up Appointment after Discharge

   ___ Your child needs to be rechecked and has an appointment on _____________ at _______ with _________________________.

   ___ Your child needs to be rechecked in ________ days. Call your child's doctor to make an appointment.

   ___ A follow-up appointment is not necessary. Call your doctor if you have any concerns.

6. Call your doctor if any of the following occur (phone: : ___________)
   • _______________________________________________________
   • _______________________________________________________
   • _______________________________________________________
7. Caregiver's name ___________________________________

   Caregiver phone number ________________________

   Date___________

Written by B.D. Schmitt, MD, and Robert Brayden, MD.
Published by RelayHealth.
© 2009 RelayHealth and/or its affiliates. All Rights Reserved.