Discharge Instruction Sheet Discharge Date

							                                            CVA/TIA
                                  Cerebral Vascular Accident/
                                   Transient Ischemic Attack
                                 Discharge Instruction Sheet                                 addressograph



Discharge Date:_____________                                                        Valuables returned   Yes           No       N/A
   Home without services                                                            Medications returned Yes           No       N/A
   Home with services                           Arranged by:________________

      SERVICE REQUESTED                              AGENCY                 START DATE              CONTACT PERSON PHONE
Stroke Rehabilitation Facility
Home Health Aid
Homemaker
Meals on Wheels
Rehab (PT/OT/Speech)
Labs:

     SPECIAL INSTRUCTIONS:        SEEK IMMEDIATE MEDICAL ATTENTION IF YOU EXPERIENCE:
                   *Sudden numbness/weakness in hand, arm, or leg
                   *Can not feel one side of face or body
                   *Suddenly can not see out of one eye
                   *Can not understand what someone is saying or difficulty speaking
                   *Feel dizzy, lose balance, or sudden falls
                   *Experience a severe headache

MEDICATIONS: If you are taking any medications not on this list, please check with your doctor
        AVOID USE OF ALCOHOL UNLESS APPROVED BY YOUR DOCTOR
                     Medication                                          Last Dose Given       Prescription Given




FOLLOW-UP APPOINTMENTS                                                 DIET:




PATIENT EDUCATION:
  Stroke/TIA Education Packet                                              Diabetic Teaching Packet
  Smoking Cessation Packet                                                 Non-Smoker


The above plan has been reviewed with me, my questions have been answered, and I understand the contents.



Signature of Patient/Significant Other   Date                          Nurse Signature           Unit        Date


If you have any questions please call (508) 422-______                              White - Patient            Yellow - Chart


Form # 330                   N:Performance Improvement/Stroke/dc_instructions_cva_tia_0107