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COMPLETE FORM IN WARD UPON DISCHARGE OR DEATH OF PATIENT

 

Final outcome:    Deceased   Discharged   Transferred to other facility

 

If Deceased ,   date of death:  ____ /____ / 2014   

                                                                DD    /    MM   /     YYYY

 

If Discharged ,   

    Discharge type: By staff   Self-discharged  Removed by family   Unknown

 

    Did the patient have a confirmed negative test for Ebola?    YES     NO     

If yes , never had Ebola (discharged from suspect ward)

                 OR

            recovered from Ebola (discharged from recovery ward)   

 

    Discharge medications provided? 

             If yes , list medications ____________________________________________

 

 

If Transferred to other facility ,   

       Reason for transfer: _________________________________________________

 

       Name of new facility: ________________________________________________

 

       District/town of new facility: __________________________________________

 

       Discharge medications provided? 

              If yes , list medications _____________________________________________

 

 

Form completed by (print name): _______________________________________

 

Signature:  __________________________________________________________