Inpatient Discharge Planning Questionnaire

Inpatient Discharge Planning Questionnaire — Form Fields

This healthcare template includes 9 fields. Gather information from patients and families to plan safe and appropriate hospital discharge. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Admission Date (text, required)
• Primary Diagnosis (text, required)
• Primary Care Physician (text, optional)
• Living situation upon discharge (multiple choice, required) — options: Alone, With family or caregiver, Assisted living, Nursing facility, Homeless or unstable housing
• Do you have a caregiver at home who can assist with recovery? (multiple choice, required) — options: Yes, No, Uncertain
• Anticipated Discharge Needs (checkboxes, optional) — options: Home health aide, Physical or occupational therapy, Wound care, Medication management, Medical equipment, Transportation, Meals on Wheels
• Concerns about going home (long text, optional)
• Emergency Contact Name and Relationship (text, required)