Contra Costa County COVID Hospital Discharge Form
PLEASE NOTE: No clearance or follow up needed if patient can isolate at home safely & patient has
been given isolation instructions for home isolation
Primary Care Physician:__________________________________________
PCP Phone Number:____________________________________________
Pharmacy:____________________________________________________
Relationship:_ _
PhoneNumber:
Deceased? Yes No Please include discharge or death note and H/P if patient has died while hospitalized
Hospital Contact Name & Phone Number:
Hospitalist/ Attending name & Phone Number:
HOSPITAL COURSE & DISCHARGE INFORMATION
Date of Positive COVID Test:
Chief Complaint (Primary Symptom):
Date of Onset of Symptom:
Initial Symptom/s & if they are resolved or improving:
Last fever (>100.4F or >38 C) Date:
Last date/time Antipyretic given (i.e. Tylenol):
Is the patient stable? Yes No
Does the patient need Hemodialysis? Yes No
Did Patient spend time in ICU? Yes No
Does the patient need: Home O2, Wound Vac IV Antibiotic Tx Home Health Service Skilled Nursing
Facility? Please describe:
Where will the patient be discharged?
Home SNF LTC ARU Sub-Acute B & C ALF
Is patient Homeless? Yes No Is patient in need of alternative housing: Yes No
At Home is there a separate bedroom available?
Yes No
Separate bathroom? Is patient Able to self-isolate safely?
Yes No
Are there any vulnerable people living with the patient? (>65 y/o, young children, conditions, or those needing home health/hospice etc)
Please E-mail this template to cocohelp@cchealth.org within 1-2 days for anticipated discharges, and you will be
contacted within 1 business day. The email needs to be ENCRYPTED with this template attached.
You may also call 925-313-6740, 7 days a week, 8am-4:30pm if more urgent concerns.
For home isolation and home quarantine: https://www.coronavirus.cchealth.org/for-covid-19-patients.
Contra Costa Health Orders isolation and quarantine which can be found on: https://www.coronavirus.cchealth.org/health-orders
