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Emergency Room Discharge
This emergency room discharge template provides the basic paperwork for when patients leave the emergency room. Customize this form by inserting your hospital procedures for documenting and authorizing release from emergency room services.

Free Sample Template
Format: Word PDF
# of Pages: 1
Printable: Yes


Emergency Room Discharge TemplateForm 2137
Format: Word PDF
Category: Medical, Hospital
Type: Form

Emergency Room Discharge

Date: ___/___/_____

Log No.:__________

Name: ________________________________________________________________________________________

Address: ______________________________________________________________________________________

City: _____________________________________ State: __________ Zip Code: ____________________________

Phone Number: ________________________________________________________________________________

Email Address: _________________________________________________________________________________

___ Male ___ Female DOB: ___/___/_____

ARRIVAL:

___/___/_____ Time: _____: _____ AM / PM

Transportation to Hospital: ___ Private Vehicle ___ Ambulance ___ Other: _________________________________

Vital Signs:

Time

Arrival

Discharge

BP

Pulse

Repertory

Temperature

Weight

Emergency Care Category:

Emergent

Urgent

Non-Urgent

Condition Upon Discharge:

Improved

Unchanged

Deteriorated

Time of Discharge: _____:_____ AM / PM