MY DISCHARGE PLAN
MY DISCHARGE INSTRUCTIONS
Instructions
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 I know why I was admitted to the hospital? ____________________________________________________
n Do I know where I am going when I’m discharged? ________________________________________________
n What are my discharge instructions? ____________________________________________________________
n Do I have any restrictions and, if so, what? _______________________________________________________
n Do I understand my restrictions? ________________________________________________________________
n Who do I call if I have questions? _______________________________________________________________
n Do you have support in place that can help you (this may need to be 24-hour care)?
Name:______________________________________________ Phone Number:___________________________
n What is the phone number? ____________________________________________________________________
n When should I call (reason)? ____________________________________________________________________
n Do you have someone to pick you up on the day of discharge?
Name:______________________________________________ Phone Number:___________________________
n Did I get my discharge medication list?___________________________________________________________
n What type(s) of follow-up care may you need?
n Home Health
n Physical Therapy
n Follow-Up Appointments
n Do I understand what medications to take, when, and how much?___________________________________
n Occupational Therapy
n Do I understand what the medications are for?____________________________________________________
n Equipment:___________________________________________________
n Who should be called for equipment delivery?
Name:______________________________________________ Phone Number:___________________________
n Dressing
n Using the Bathroom
n Cooking
n Climbing Stairs
n Doctor’s Appointments
n Shower Bars
n Bedroom Locations
n I 2F