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Hospital Discharge Worksheet

Prepare for a safer transition from hospital to home, rehab, skilled nursing, assisted living, or another care setting.

Privacy-friendly: no account, no email, and no personal information submitted to this site.

Patient name
Hospital
Date
Primary caregiver
Phone number

Take this worksheet to the hospital. Use it while talking with nurses, doctors, discharge planners, rehab providers, home health agencies, facility staff, and family helpers.

This worksheet is for organizing questions and next steps. It is not medical advice. Ask the care team what applies to this patient.

Do not write Social Security numbers, insurance IDs, account numbers, passwords, or portal credentials on this worksheet.

Section 1

Discharge Snapshot

FieldInformation
Diagnosis or reason for hospitalization
Admitting date
Expected discharge date
Discharge destination Home Rehab Skilled nursing Assisted living Other
Primary discharge contact
Care team contacts

Care team names and phone numbers:

RoleNamePhoneNotes
Doctor
Nurse
Discharge planner / case manager
Social worker
Therapist
Other

Main discharge concern:

Section 2

Questions For The Care Team

Ask before discharge. Write down the answers.

QuestionAnswer
Why was the patient hospitalized?
What changed?
What warning signs require urgent help?
Who should we call with questions?
What follow-up appointments are required?

Additional questions:

Section 3

Medication Changes

Verify medication changes with the care team and pharmacy. Do not stop, start, or change medication without asking the doctor, pharmacist, or care team.

New Medications

MedicationWhy addedWhen takenWho prescribed itQuestions

Stopped Medications

MedicationWhy stoppedWho stopped itQuestions

Changed Medications

MedicationWhat changedWhy changedWho changed itQuestions

Questions For Pharmacist

Section 4

Home Readiness Check

The discharge plan has to work in the actual home, with the actual people available.

  • Food available.
  • Water available.
  • Bathroom accessible.
  • Bed accessible.
  • Phone accessible.
  • Transportation available.
  • Stairs manageable.
  • Lighting adequate.
  • Caregiver available.
  • Emergency contacts available.

Home concerns to solve before discharge:

Who is checking the home?

When will the home be checked?

Section 5

Equipment And Supplies

Ask what is needed, who orders it, who pays or verifies coverage, when it arrives, and what to do if it does not arrive in time.

Equipment or supplyNeeded?Ordered?Received?Questions
Walker Yes No Unsure Yes No Unsure Yes No Unsure
Wheelchair Yes No Unsure Yes No Unsure Yes No Unsure
Oxygen Yes No Unsure Yes No Unsure Yes No Unsure
Hospital bed Yes No Unsure Yes No Unsure Yes No Unsure
Shower chair Yes No Unsure Yes No Unsure Yes No Unsure
Commode Yes No Unsure Yes No Unsure Yes No Unsure
Other equipment Yes No Unsure Yes No Unsure Yes No Unsure
Other supplies Yes No Unsure Yes No Unsure Yes No Unsure

Equipment delivery contact:

What if equipment is delayed?

Section 6

Care Tasks After Discharge

This is a key section. The plan has to match the help actually available.

TaskWho will do itBackup person
Medication management
Wound care
Mobility help
Bathing
Meals
Transportation
Appointments
Toileting or bathroom help
Overnight supervision
Equipment setup
Family updates
Other: ____________________

Care tasks no one has agreed to yet:

Who can help if the primary caregiver cannot?

Section 7

Follow-Up Appointments

ProviderDateLocationTransportation PlanNotes

Appointments that still need to be scheduled:

Section 8

Questions That Are Still Unanswered

Do not leave important uncertainty in someone’s memory. Write it down before discharge.

Notes:

Section 9

If The Plan Is Not Working

Ask these before discharge.

QuestionAnswer
Who do we call?
What symptoms require urgent help?
What problems should trigger a follow-up call?
What should be escalated immediately?

Call immediately if the care team says these warning signs happen:

Problems that should trigger a follow-up call:

After-hours contact:

Final Page

Discharge Readiness Checklist

Before discharge, check:

  • Medication changes understood.
  • Follow-up appointments scheduled.
  • Equipment received.
  • Home safety checked.
  • Transportation arranged.
  • Caregiver assigned.
  • Backup caregiver identified.
  • Questions answered.
  • Emergency contacts available.
Date reviewed

Reviewed with:

Main thing that still feels uncertain:

Works Well With