Restrictive Eating Disorder Discharge Plan

Appendix 3

NAME ______

CH MR# ______

DOB: ______Restrictive Eating Disorders Clinical Practice Guideline Discharge Plan Admission Date ______Resident Physician ______Discharge Date ______Attending Physician ______Discharge Diagnosis: Primary ______Primary Nurse ______Secondary ______Discharge to:  Home  Other:______You/Your child should take the following medicines: Medicine How much to take When to take it Notes  Neutra-Phos® 1 packet Twice a day by mouth Mix with 4 ounces of juice.  Multivitamin with Zinc 1 tablet Every morning by mouth Special Instructions Goals after discharge:______. Meals times:______Snack times:______. Meal time strategies:______. Food plan:______. Exercise/Activity guidelines:______. Weight guidelines:______. (Guidelines to be determined by outpatient treatment team, along with expectations for weight gain.) ______Follow up Appointments Bring journal and meal journal to appointments. It is important to follow-up with all appointments. If you are unable to keep an appointment, you need to reschedule. Pediatrician: ______Date & Time:______Phone: ______Therapist:______Date & Time:______Phone:______Eating Disorder Doctor: ______Date & Time:______Phone: ______Family Therapist: ______Date & Time:______Phone: ______School Counselor/Nurse: ______Date & Time:______Phone: ______Psychiatrist: ______Date & Time:______Phone: ______Nutritionist: ______Date & Time:______Phone: ______In Home Support: ______Date & Time:______Phone: ______Crisis Contact Person: ______Date & Time:______Phone: ______Other: ______Date & Time:______Phone: ______I acknowledge my participation in, review of and agreement with the above plan. I have received a written copy, my questions have been answered, and I understand the contents. I understand that, in order to arrange necessary services, relevant medical and other information is being released to the above-listed providers.

______Date ______Date ______(Signature of patient/parent/legal guardian) (Signature of preparing/discharging nurse) Please bring this form with you to your next clinic/hospital visit. Appendix 3

______Date ______Date ______(Signature of patient/parent/legal guardian) (Signature of preparing/discharging nurse) Please bring this form with you to your next clinic/hospital visit.