MY DISCHARGE PLAN
Check the box next to each item when you and your caregiver complete it.
n My expected discharge day is:___________________________________________________________________
n Ask where you will get care after discharge. Do you have options (i.e. home health care)?
_______________________________________________________________________________________________
n Do you have support in place that can help you (this may need to be 24-hour care)?
Name:______________________________________________ Phone Number:___________________________
n Do you have someone to pick you up on the day of discharge?
Name:______________________________________________ Phone Number:___________________________
n What type(s) of follow-up care may you need?
n Home Health
n Physical Therapy
n Follow-Up Appointments
n Occupational Therapy
n Equipment:___________________________________________________
n Who should be called for equipment delivery?
Name:______________________________________________ Phone Number:___________________________
n Ask your Care Team if you are ready to do the activities listed below:
n Bathing
n Dressing
n Using the Bathroom
n Cooking
n Climbing Stairs
n Picking up Prescriptions
n Food Shopping
n Doctor’s Appointments
n Will you be able to get in and around your home without difficulty?
n Door Widths
n Shower Bars
n Bedroom Locations
n Ramps
n Other:_____________________________________________________________________________________
n Is there care you must do at home (i.e. trach care, tube feedings, etc.)?
n Have you been shown how to perform these tasks?
n Are you comfortable performing these tasks?
n YES
n YES
n YES
n NO
n NO
n NO
Notes to families and caregivers: If you plan to assist the patient with care at home, please make plans to be at
their hospital bedside to learn about how to help your loved one. If there are special care needs (e.g. changing
dressings, turning and skin care, use of feeding tubes, giving shots, etc.), you will need time to learn about
these needs and practice with the help of the nurses.
THE DAY BEFORE DISCHARGE
Your care team anticipates that you will go home tomorrow by noon. Please remind your ride of the need to
be at the hospital early to help with your safe and timely transport home.
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