PATIENT DISCHARGE CHECKLIST: CARE TRANSITIONS & FOLLOW-UP

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--- DISCHARGE PLANNING & ASSESSMENT ---
[ ] Date of Initial Discharge Planning Meeting
[ ] Patient's Goals for Post-Discharge Recovery
[ ] Patient's Living Situation Post-Discharge (Home, Assisted Living, Skilled Nursing Facility, Other)
[ ] Number of Caregivers Available
[ ] Summary of Patient and Family Concerns/Questions
[ ] Patient's Understanding of Discharge Instructions (Excellent, Good, Fair, Poor)

--- MEDICATION RECONCILIATION & INSTRUCTIONS ---
[ ] Patient Name
[ ] Current Medication List (as reported by patient/family)
[ ] Hospital/Facility Medication List
[ ] Discharged Medication List (Name, Dosage, Frequency, Route)
[ ] Medication Reconciliation Discrepancies? (Yes, No)
[ ] Explanation of Discrepancies & Resolution
[ ] Patient Understanding of Medications? (Yes, No, Partially)
[ ] Additional Instructions/Education Provided

--- FOLLOW-UP APPOINTMENTS & REFERRALS ---
[ ] Primary Care Physician Follow-Up Date
[ ] Specialist Appointment Date (e.g., Cardiology, Neurology)
[ ] Referral Needed? (Yes, No)
[ ] Referral Specialty (if applicable) (Cardiology, Neurology, Physical Therapy, Other)
[ ] Specialist Physician Name (if applicable)
[ ] Referral Notes/Instructions (for referring physician)
[ ] Appointment Location (address)
[ ] Appointment Time

--- HOME HEALTH & SUPPORT SERVICES ---
[ ] Home Health Agency Selected? (Yes, No, Pending)
[ ] Home Health Agency Contact Information
[ ] Physical Therapy Required? (Yes, No, Unsure)
[ ] Estimated Home Health Visit Frequency (per week)
[ ] Support Services Requested (check all that apply) (Meals on Wheels, Transportation Services, Respite Care, Social Worker Consultation, Other (please specify in long text field))
[ ] Other Support Services Notes (if applicable)

--- PATIENT & FAMILY EDUCATION ---
[ ] Explanation of Diagnosis & Condition
[ ] Medication Instructions (Dosage, Timing, Side Effects)
[ ] Potential Complications & Warning Signs
[ ] Dietary Recommendations & Restrictions
[ ] Received Instructions on Wound Care (if applicable) (Yes, No)
[ ] Understanding of Follow-Up Appointment Schedule (Excellent, Good, Fair, Poor)
[ ] Patient Acknowledgement of Education

--- DISCHARGE DOCUMENTATION & LEGAL ---
[ ] Physician Signature
[ ] Date of Discharge Order
[ ] Advanced Directives Status (Exists & Reviewed, Exists & Not Reviewed, Does Not Exist)
[ ] Summary of Patient Concerns/Questions
[ ] Relevant Legal Documents (if applicable)
[ ] HIPAA Acknowledgement (Patient Acknowledges HIPAA Rights, Patient Unable to Acknowledge)

--- EQUIPMENT & SUPPLIES ---
[ ] Needed Durable Medical Equipment (DME) (Walker, Crutches, Wheelchair, Hospital Bed, Oxygen Concentrator, Other (Specify Below))
[ ] Other DME Specifications (If selected above)
[ ] Quantity of Wound Care Supplies
[ ] Prescription for Home Health Supplies (if applicable)
[ ] Supplier for Equipment & Supplies (Hospital Supplier, Patient's Preferred Supplier, Other (Specify Below))
[ ] Other Supplier Information

--- TRANSPORTATION & LOGISTICS ---
[ ] Mode of Transportation (Ambulance, Private Vehicle, Public Transportation, Hospital Transport, Taxi/Ride-Sharing)
[ ] Driver Name (if applicable)
[ ] Vehicle License Plate Number (if applicable)
[ ] Destination Address
[ ] Scheduled Departure Time
[ ] Driver Signature (Confirmation)

--- FINAL REVIEW & SIGN-OFF ---
[ ] Physician Signature
[ ] Nurse Signature
[ ] Case Manager Signature (if applicable)
[ ] Discharge Instructions Reviewed with Patient/Family? (Yes, No)
[ ] Patient Identification Verification Score (1-10)
[ ] Date of Final Review
[ ] Time of Final Review
[ ] Comments/Notes Regarding Final Review

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