Discharge Planning Checklist
Discharge Planning Checklist
Discharge Planning Checklist
Discharge
Planning
Checklist:
For patients and their caregivers
preparing to leave a hospital, nursing home,
or other care setting
1
Name:
Reason for admission:
During your stay, your doctor and the staff will work with you to plan for
your discharge. You and your caregiver (a family member or friend who may
be helping you) are important members of the planning team. You and your
caregiver can use this checklist to prepare for your discharge.
Instructions:
• Use this checklist early and often during your stay.
• Talk to your doctor and the staff (like a discharge planner, social worker, or nurse)
about the items on this checklist.
• Check the box next to each item when you and your caregiver complete it.
• Use the notes column to write down important information
(like names and phone numbers).
• Skip any items that don’t apply to you.
If a caregiver will be helping you after discharge,
write down their name and phone number.
Your health
Ask the staff about your health condition and what
you can do to help yourself get better.
Ask about problems to watch for and what to do
about them. Write down a name and phone number
of a person to call if you have problems.
2
Action items
Use “My drug list”on page 5 to write down your
prescription drugs, over-the-counter drugs, vitamins,
and herbal supplements.
Review the list with the staff.
Tell the staff what drugs, vitamins, or supplements
you took before you were admitted. Ask if you
should still take these after you leave.
Write down a name and phone number of a person
to call if you have questions.
3
Action items Notes
Ask for written discharge instructions (that you can read
and understand) and a summary of your current health
status. Bring this information and your completed
“My drug list” to your follow-up appointments.
Use “My appointments” on page 5 to write down
any appointments and tests you’ll need in the next
several weeks.
Can you give the patient the help he or she needs?
What tasks do you need help with?
Do you need any education or training?
Talk to the staff about getting the help you need
before discharge.
Write down a name and phone number of a person
you can call if you have questions.
Get prescriptions and any special diet instructions early,
so you won’t have to make extra trips after discharge.
4
My drug list Filled out on: _________________
Fill out this list with all prescription drugs, over-the-counter drugs, vitamins, and herbal supplements you
take. Review this list with the staff.
If you have Medicare and limited income and resources, you may qualify for Extra Help to pay for your
Medicare prescription drug coverage. For more information about Extra Help, visit Medicare.gov.
Drug name
DRUG NAME What IT
WHAT it does
DOES Dose
DOSE How TO
HOW to take
TAKE itIT WHEN
When TO
to TAKE
take itIT Notes
NOTES
My appointments
APPOINTMENTS
AppointmentsAND
andTESTS
tests DATE
Date PHONEnumber
Phone NUMBER
5
Resources
The agencies listed here have information on community services,
(like home-delivered meals and rides to appointments). You can
also get help making long-term care decisions. Ask the staff in
your health care setting for more information.
Area Agencies on Aging (AAAs) and Aging and Disability Resource Centers (ADRCs):
Helps older adults, people with disabilities, and their caregivers. To find the AAA or ADRC in your
area, visit the Eldercare Locator at eldercare.gov, or call 1-800-677-1116.
Medicare: Provides information and support to caregivers of people with Medicare.
Visit Medicare.gov.
Long-Term Care (LTC) Ombudsman Program: Advocates for and promotes the rights of
residents in LTC facilities. Visit ltcombudsman.org.
Senior Medicare Patrol (SMP) Programs: Works with seniors to protect themselves from
the economic and health-related consequences of Medicare and Medicaid fraud, error, and
abuse. To find a local SMP program, visit smpresource.org.
Centers for Independent Living (CILs): Helps people with disabilities live independently.
For a state-by-state directory of CILs, visit ilru.org/html/publications/directory/index.html.
State Technology Assistance Project: Has information on medical equipment and other
assistive technology. Visit resna.org, or call 1-703-524-6686 to get the contact information in
your state.
National Long-Term Care Clearinghouse: Provides information and resources to plan for
your long-term care needs. Visit longtermcare.gov.
National Council on Aging: Provides information about programs that help pay for
prescription drugs, utility bills, meals, health care, and more. Visit benefitscheckup.org.
State Health Insurance Assistance Programs (SHIPs): Offers counseling on health
insurance and programs for people with limited income. Also helps with claims, billing, and
appeals. Visit shiptacenter.org, or call 1-800-MEDICARE (1-800-633-4227) to get your SHIP’s
phone number. TTY users can call 1-877-486-2048.
Medicaid: Helps with medical costs for some people with limited income and resources. To find
your local office, visit Medicare.gov/contacts, or call 1-800-MEDICARE.
The information in this booklet describes the Medicare program at the time this booklet was printed. Changes may occur after printing. Visit
Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227) to get the most current information. TTY users can call 1-877-486-2048.
“Your Discharge Planning Checklist” isn’t a legal document. Official Medicare Program legal guidance is contained in the relevant
statutes, regulations, and rulings.
You have the right to get the information in this product in an alternate format. You also have the right to file a complaint if you feel
you’ve been discriminated against. Visit CMS.gov/about-cms/agency-information/aboutwebsite/cmsnondiscriminationnotice.html,
or call 1-800-MEDICARE for more information.