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Home > Protecting Children in Substance-Abusing Families > Protecting Children in Substance-Abusing Families : Table 1 : Hospital Form For Discharge Of Infants

 

 

Protecting Children in Substance-Abusing Families
User Manual Series (1994)
Author(s):  U.S. Department of Health and Human Services
Kropenske, Howard, Breitenbach, Dembo, et al.
Year Published:  1994



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Table 1 : Hospital Form For Discharge Of Infants

DISCHARGE INFORMATION SHEET
FOR THE NEWBORN
DATE:
RE: INFANT'S NAME AKA: D.O.B. HOSPITAL I.D.#
REASON FOR OUT-OF-HOME PLACEMENT, IF APPLICABLE
POLICE OR DCS HOLD VOLUNTARY PLACEMENT
ADOPTION PLACEMENT FOR MEDICAL REASONS
BIRTH INFORMATION:
WEIGHT AT BIRTH: LENGTH: HEAD CIRCUMFERENCE:
APGAR 1 MINUTE: 5 MINUTE: GESTATIONAL AGE BY PHYSICAL EXAM:
PERINATAL COMPLICATIONS:
 
 
 
ADMISSION DATE:         DISCHARGE DATE:         DISCHARGE WEIGHT:        
ABNORMAL FINDINGS CURRENT STATUS REQUIRED FOLLOW UP
1.      
2.      
3.      
GENERAL CONDITION UPON DISCHARGE:
NURSING INFORMATION:
FEEDING/DIET
  
MEDICATIONS
  
SPECIAL OBSERVATIONS/INSTRUCTIONS
  
  
SCHEDULED APPOINTMENTS:
LOCATION:   DATE:   TIME:   PHONE:  
1.
2.
3.
Home Health Referral Agency Name:
yes no
Contact Person:
   Phone Number:
Signature:                     M.D.
Phone:
Social Worker      Phone:
In emergency, if above professionals cannot be reached,
contact:
Weekdays 8-5 PM:
213.825.5431
Weeknights/Weekends/Holidays
213.825.2111

DISCHARGE INFORMATION SHEET FOR THE NEWBORN

 

DIST:(1)White–Medical Record/(2)Canary–Children's Services Worker/(3)Pink–Foster Parents/(4)G/Rod–Clinical Social Work



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