Discharge Checklist for Patients Getting Ready for Discharge:
Discharge Checklist for Patients
It is important to be prepared when you leave the hospital. This checklist can help make sure you know key information to stay safe and healthy so you do not have to return to the hospital. It contains a set of statements about your hospital stay, your discharge instructions, and your follow-up care plan (diagnoses, treatment goals, care at home, etc.). Together, you, your caregivers, and your discharge team can use this checklist so you have the information you need before you're discharged.
Instructions:
- Ideally, you should be able to answer "yes" to all statements that apply to you.
- Make sure to talk to your health care team about any statement you marked "no."
- Use the notes section to record any additional details or information.
| During Your Hospital Stay 1-3 - I understand why I stayed in the hospital. | During Your Hospital Stay 1-3 - YES | During Your Hospital Stay 1-3 - NO | During Your Hospital Stay 1-3 - DOES NOT APPLY |
|---|---|---|---|
| My family and caregivers know the details about my hospital stay. | YES | NO | DOES NOT APPLY |
| I can explain the tests and treatments I had while in the hospital. | YES | NO | DOES NOT APPLY |
| I'm aware of test results that might come in after my hospital stay. | YES | NO | DOES NOT APPLY |
| I know … … when these results will be available | YES | NO | DOES NOT APPLY |
| … who to call to get these results | YES | NO | DOES NOT APPLY |
| I can explain the surgeries or other procedures I had while in the hospital. | YES | NO | DOES NOT APPLY |
Notes:
| As You Get Ready to Leave the Hospital 1-5 - I/my caregiver received a summary of my hospital visit. | As You Get Ready to Leave the Hospital 1-5 - YES | As You Get Ready to Leave the Hospital 1-5 - NO | As You Get Ready to Leave the Hospital 1-5 - DOES NOT APPLY |
|---|---|---|---|
| My care plan addresses my treatment goals, wants, needs, and concerns; I feel ready to leave the hospital. | YES | NO | DOES NOT APPLY |
| My family and caregivers have been included in my care plan (diagnoses, treatment goals, care at home, etc.) after I leave the hospital. | YES | NO | DOES NOT APPLY |
| I/my caregiver received a copy of my medical records to give to my health care team outside the hospital. | YES | NO | DOES NOT APPLY |
| I/my caregiver received a printout of the instructions I need to follow. | YES | NO | DOES NOT APPLY |
| I have a plan for getting home or to the next site of care. | YES | NO | DOES NOT APPLY |
| I can give the name and phone number of the person who will pick me up from the hospital. | YES | NO | DOES NOT APPLY |
| There is a plan in place for getting special medical equipment and supplies I need. I know … | YES | NO | DOES NOT APPLY |
| … how and from where I will get these supplies | YES | NO | DOES NOT APPLY |
| … who will help me if I need to pick them up | YES | NO | DOES NOT APPLY |
| … how I will pay for them | YES | NO | DOES NOT APPLY |
| There is a plan in place for getting the medicines I need. I know … | YES | NO | DOES NOT APPLY |
| … how and where I will get them | YES | NO | DOES NOT APPLY |
| … who will help me if I need to pick them up | YES | NO | DOES NOT APPLY |
| … how I will pay for them | YES | NO | DOES NOT APPLY |
| I know my drug allergies. | YES | NO | DOES NOT APPLY |
As You Get Ready to Leave the Hospital 1-5 (cont'd)
| I have a list of all of the medications I should take when I get | YES | NO | DOES NOT APPLY |
|---|---|---|---|
| home. | |||
| I know … | |||
| … medications to take the day I leave the hospital | YES | NO | DOES NOT APPLY |
| … changes that were made to the medications I was taking before going to the hospital, including medications that I should stop | YES | NO | DOES NOT APPLY |
| taking … new medications that were started while I was in the hospital | YES | NO | DOES NOT APPLY |
| I have reviewed my home medication regimen with my care team. | YES | NO | DOES NOT APPLY |
| For each medicine, I know … | |||
| … the name of the medicine and why I am taking it | YES | NO | DOES NOT APPLY |
| … how many times a day and at what time(s) I should take the medicine | YES | NO | DOES NOT APPLY |
| … how much of the medicine I should take | YES | NO | DOES NOT APPLY |
| … if I should take the medicine with or without food | YES | NO | DOES NOT APPLY |
| … if there is anything I should not eat or drink when taking the medicine | YES | NO | DOES NOT APPLY |
| … how long the medicine takes to work | YES | NO | DOES NOT APPLY |
| … if the medicine will cause problems if I take it with other medicine(s) | YES | NO | DOES NOT APPLY |
| … if it is safe for me to drive while taking the medicine | YES | NO | DOES NOT APPLY |
| … what "as needed" means | YES | NO | DOES NOT APPLY |
| … when I should stop taking the medicine | YES | NO | DOES NOT APPLY |
| … what I should do if I forget to take my medicine | YES | NO | DOES NOT APPLY |
| … what side effects I can expect and what I should do if I have a problem | YES | NO | DOES NOT APPLY |
| … if I will need a refill and how to arrange that | YES | NO | DOES NOT APPLY |
Notes:
Discharge Checklist for Patients
| After You Leave the Hospital 4,5 - I am aware of problems to watch for when I get home and when I should call someone. | After You Leave the Hospital 4,5 - YES | After You Leave the Hospital 4,5 - NO | After You Leave the Hospital 4,5 - DOES NOT APPLY |
|---|---|---|---|
| I have the name and phone number of the person to call if I have problems or questions. | YES | NO | DOES NOT APPLY |
| I understand that I may need help or medical care (for example: physical therapy, caring for a bandage, etc.) after I am discharged. | YES | NO | DOES NOT APPLY |
| I know … … what kind of help or care I need | YES | NO | DOES NOT APPLY |
| … what health care services I will receive | YES | NO | DOES NOT APPLY |
| … who is providing the help and care I need | YES | NO | DOES NOT APPLY |
| There is a plan in place for follow-up visits with my health care team. | YES | NO | DOES NOT APPLY |
| I know … … which appointments have already been made | YES | NO | DOES NOT APPLY |
| … when and where I need to go for my appointments | YES | NO | DOES NOT APPLY |
| … which appointments still need to be made | YES | NO | DOES NOT APPLY |
| … how I will get to these appointments | YES | NO | DOES NOT APPLY |
| I have a good idea about what life at home will be like. I know … … if I should be eating a certain diet | YES | NO | DOES NOT APPLY |
| … what activities I should be doing | YES | NO | DOES NOT APPLY |
| … what activities I should avoid | YES | NO | DOES NOT APPLY |
| I know what is needed to make my home safer for me. | YES | NO | DOES NOT APPLY |
Notes:
Discharge Checklist for Patients
Places to Go for More Information*
US Administration on Aging: Helps adults 60 years and older and caregivers by finding resources in your community. To find your local Area Agency on Aging, call the Eldercare Locator at 1-800-677-1116 or visit https:// eldercare.acl.gov.
National Association of Area Agencies on Aging: Offers a wide range of information and resources for older adults, people with disabilities, and caregivers. Visit www.n4a.org/.
Centers for Independent Living: Help people with disabilities live independently. For a state-by-state directory, visit www.ilru.org/html/ publications/directory/index.html.
Long-Term Care Ombudsman program:
Advocates for, and promotes the rights of, residents in long-term care facilities. Visit https:// Ltcombudsman.org.
Medicare: For more information about what Medicare covers, call 1-800-MEDICARE (1-800633-4227), or visit www.medicare.gov. TTY users should call 1-877-486-2048.
National Council on Aging: Provides information about programs that help pay for prescription drugs, utility bills, meals, health care, and more. Visit www.benefitscheckup.org.
State Health Insurance Assistance
Programs (SHIP): Offer counseling on health insurance and programs for people with limited income. Also help with claims, billing, and appeals. Visit www.shiptacenter.org/, or call 1-800-MEDICARE (1-800-633-4227) to get the contact information for a SHIP program in your state. TTY users should call 1-877-486-2048.
State Medical Assistance (Medicaid)
office: Provides information about Medicaid. To find your local office, call 1-877-267-2323 or visit www.medicaid.gov. TTY users should call 1-866-226-1819.
Family Caregiver Alliance: Provides information and resources on discharge planning and other topics to help support caregivers who provide care for adults. Visit www.caregiver. org/.
LongTermCare.gov: Provides information and resources to plan for your long-term care needs. Visit https://acl.gov/ltc.
*The Web sites listed are neither owned nor controlled by Pfizer. Pfizer is not responsible for the content or services provided by these sites.
Discharge Checklist for Patients
References
- Centers for Medicare & Medicaid Services. Your Discharge Planning Checklist: For patients and their caregivers preparing to leave a hospital, nursing home, or other care setting. Updated March 2019. Accessed May 17, 2021. https://www.medicare.gov/Pubs/ pdf/11376-discharge-planning-checklist.pdf
- Johns Hopkins Medicine. Hospital Discharge. Accessed May 17, 2021. https://www.hopkinsmedicine.org/health/treatment-tests and-therapies/hospital-discharge
- Agency for Healthcare Research and Quality (AHRQ). Care Transitions from Hospital to Home: IDEAL Discharge Planning Training. Accessed May 17, 2021. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/ strategy4/Strat4_Tool_4_PPT_508.pdf
- Agency for Healthcare Research and Quality (AHRQ). Be Prepared to Go Home Checklist. Accessed May 17, 2021. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_2a_ IDEAL_Checklist_508.pdf
- Agency for Healthcare Research and Quality (AHRQ). Taking Care of Myself: A Guide for When I Leave the Hospital. Accessed May 17, 2021. https://www.ahrq.gov/questions/resources/going-home/index.html
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