Hospital Discharge Checklist

Hospital Discharge Checklist — Form Fields

This healthcare template includes 5 fields. Verify that all discharge criteria have been met before a patient leaves the hospital. Ensures patients receive education, follow-up appointments, and prescriptions. Reduces avoidable readmissions through comprehensive discharge planning. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Discharging Nurse / Provider (text, required)
• Discharge Destination (dropdown selection, required) — options: Home – independent, Home – with home health services, Skilled nursing facility, Rehabilitation facility, Assisted living / long-term care
• Discharge criteria verified (checkboxes, required) — options: Discharge instructions provided and reviewed with patient, Prescriptions given or sent to pharmacy, Follow-up appointment scheduled, Transportation confirmed, Medication reconciliation completed, Patient verbalized understanding of discharge plan
• Patient's condition at time of discharge (multiple choice, required) — options: Stable – meets discharge criteria, Discharged against medical advice (AMA)