DISCHARGE PLANNING FORM

Registered No.
: 25
Name
: Barry
Sex
: Male
Date of hospitalized : November, 7th 2014

Address

: Limau Manis Street, Pauh

District
Room Care
: Orchid room
Date of out of hospital : November, 10th 2014

Hospitalized diagnose : Celiac Desease

Nursing Diagnose : Diarrhea

Out of hospital diagnose : Celiac Desease

Dietary :

1. Consume 3 times in a day with contain carbohydrate ( except the food with contain
gluten or wheat), protein, vegetables & fruits.
2. Drink a glass of milk at morning & a glass of milk at night
3. Avoid foods or drinks with contain gluten, like: wheat, oats, bread , etc.
Drugs, dosage, colour, and side effects :

1.

Kortikosteroid:

2.

Laktulosa drugs:

3.

Vitamin supplement:

Activity and rest : total bedrest for one week before do check up/control

Date/ Place of control : November, 17th 2014 at Polyclinic RSUP M.Djamil

For brought home ( Laboratory result, ECG, Picture) :
Discharged from RSUP M.Djamil in conditions
Recover
Forced discharge
Attending clinic as outpatient
Run away
Move to other hospital
Die
Others : (Rest Letter)

Padang, 2014
Patient / Family

Nurse

(
Head Room