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Hospital Discharge Planning Checklist for Families

Key Questions Before the Patient Leaves the Medical Facility

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Patient: ____________________
Hospital/Facility: ____________________
Planned Discharge Date: ____________________
Discharge Destination: ☐ Home ☐ Home Health ☐ Skilled Nursing ☐ Rehab ☐ Other: ______________________

Doctor: ____________________
Case Manager/Discharge Planner: ____________________

 

1. Is the patient medically ready?

☐ Do I understand why the patient was hospitalized?
☐ Has a doctor explained why the patient is ready to leave?
☐ What medical problems have improved?
☐ What problems remain unresolved or still need monitoring?
☐ Have we discussed symptoms, labs, imaging, wounds, infection, oxygen needs, heart issues, confusion, weakness, falls, pain, eating, or drinking problems?
☐ Has the care team discussed the risk of return to the ER or hospital after discharge?

Unresolved medical concerns:

 

2. Can the patient function safely at the discharge destination?

☐ Can the patient get out of bed safely?
☐ Can the patient walk or transfer safely with the recommended help?
☐ Can the patient use the toilet safely?
☐ Can the patient eat and drink safely?
☐ Is the patient’s strength, balance, walking, and self-care close to baseline?
☐ If not, has the care team explained why discharge is still safe?
☐ Has physical therapy or occupational therapy evaluated the patient for mobility, fall, transfer, or self-care concerns?

Needed equipment: ☐ Walker ☐ Wheelchair ☐ Cane ☐ Commode ☐ Shower chair ☐ Hospital bed ☐ Oxygen ☐ Other: __________
☐ Has needed equipment been delivered or confirmed?

 

3. Is the patient confused, sedated, or unable to manage the plan?

☐ Is the patient alert enough to understand basic instructions?
☐ Is the patient more confused than usual?
☐ Has the patient had delirium, hallucinations, unusual sleepiness, agitation, or heavy sedation?
☐ Have medications been reviewed for confusion, dizziness, sedation, or fall risk?
☐ If the patient cannot manage the plan alone, has a responsible caregiver been identified and trained?

Responsible caregiver: ____________________
Phone: ____________________

 

4. Are medications safe and available?

☐ I have the final printed medication list.
☐ The list explains what each medication is for, dose, time, and route.
☐ New, changed, and stopped medications are clearly identified.
☐ The team explained which old medications should not be restarted.
☐ The team checked for duplicate medications, interactions, allergies, and prior reactions.
☐ Major side effects requiring a doctor call or emergency care were explained.
☐ Prescriptions were sent to the correct pharmacy.
☐ Medications will be available on the day of discharge.
☐ Someone is assigned to administer or supervise medications.

Pharmacy: ____________________
Medication manager: ______________________

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5. Is the caregiver and home plan realistic?

☐ Has the care team asked who will actually help the patient?
☐ Does the caregiver understand the amount of help needed?
☐ Can the caregiver realistically provide that help?
☐ Has the caregiver received hands-on training where needed?
☐ Is there a safe place to sleep and a safe bathroom arrangement?
☐ Can the patient get food, fluids, medications, transportation, and help at night or on weekends?
☐ Have stairs, rugs, poor lighting, pets, clutter, and fall hazards been considered?

Patient needs help with: ☐ Walking ☐ Transfers ☐ Toileting ☐ Bathing ☐ Meals ☐ Medications ☐ Wound care ☐ Oxygen ☐ Transportation ☐ Other: __________

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6. Have written instructions, red flags, and follow-up been confirmed?

☐ I have written discharge instructions in plain language.
☐ The instructions explain the diagnosis, next care, restrictions, diet, activity, wound care, and pending tests.
☐ The instructions say who will follow up on pending results.
☐ The instructions say when to call the doctor and when to call 911 or go to the ER.
☐ Primary care and specialist follow-up are scheduled or clearly assigned.
☐ Home health, therapy, nursing, or facility care is confirmed if needed.
☐ Transportation is arranged.

Call 911 / ER for: chest pain, trouble breathing, stroke symptoms, severe confusion, fainting, severe bleeding, serious fall, severe allergic reaction, or other emergency warning signs.

Doctor/clinic to call first: ____________________
After-hours number: ____________________

 

7. Medicare notice and appeal rights, if applicable

☐ The patient received the required Medicare discharge or service-ending notice.
☐ The notice explains appeal rights, deadlines, and BFCC-QIO contact information.
☐ If discharge or service termination appears too soon, appeal instructions have been reviewed before the deadline.

Notice received: ____________________
Appeal deadline: ____________________

 

Final day-of-discharge decision:

Before the patient leaves, families should confirm medications, instructions, equipment, follow-up, transportation, caregiver availability, red flags, and contact numbers.

☐ The discharge plan appears understandable and reasonably safe.
☐ The discharge plan may need correction before discharge.
☐ The discharge appears too soon, and Medicare appeal or facility review options should be considered immediately.

 

 

 

​​​This checklist is educational only and provides general information on the questions addressed. It is not a substitute for specific, individualized professional legal or medical advice and cannot be construed or relied upon as such. Outcomes cannot be guaranteed. The use of this information does not create or constitute an attorney-client relationship. Content compiled and edited by Attorney Lloyd B. Porter, licensed in California. 

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