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Appendix 1
Sample Information to Be Provided to Patients at Discharge, With a Copy Retained on the Patient Chart


Discharge instructions for the health-care provider of: ____________________________
Patient Name
This patient was discharged from ____ Outpatient Clinic of _______________________
____ Emergency Department Institution
____ Hospital
On Date: _______/_____/_____
Month / Day / Year
This patient received pre-discharge administration of:
_____ Tetanus toxoid–containing vaccine
____ DTaP Manufacturer____________ Lot # _____________
____ Tdap Manufacturer____________ Lot # _____________
____ Td Manufacturer____________ Lot # _____________
____ TT Manufacturer____________ Lot # _____________
_____ Tetanus Immune Globulin (TIG)
____ Dose Manufacturer____________ Lot # _____________
_____ Hepatitis B vaccine
Manufacturer____________ Lot # _____________
Product: _____________________ Dose: ________________________
This patient will need further evaluation regarding whether administration of a vaccine or completion of an immunization
series is needed.
Evaluate need for immunization series completion:
_____Tetanus
_____Hepatitis B
_____Other:___________________________
Assess need for evaluation of seroconversion to:
_____Hepatitis C infection
• Baseline testing for anti-HCV and alanine aminotransferase (ALT) within 7–14 days of the exposure
• Follow-up testing for anti-HCV and ALT 4–6 months after exposure to assess seroconversion
• HCV RNA test at 4–6 weeks if earlier diagnosis of HCV infection is desired
• Confirm positive anti-HCV with low signal-to-cutoff results using a more specific supplemental assay before
communicating results to patient
_____HIV infection
Follow up on the following tests collected during the acute care visit:
_______AST/ALT
_______Hepatitis C virus serology
_______HIV serology
Antibiotic or other antimicrobial given:
Specific discharge instructions that need further medical evaluation:
Wound care instructions:
Other:
 

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Date last reviewed: 7/9/2008

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