Patient Discharge Readiness Survey

Patient Discharge Readiness Survey — Form Fields

This surveys template includes 8 fields. Assess patients' understanding of care instructions, medications, and follow-up plans before discharge. Free to customize and use on ZenBuild.

• Reason for Hospital Stay (dropdown selection, required) — options: Surgery, Illness, Injury, Childbirth, Mental Health, Chronic Condition, Other
• Clarity of Discharge Instructions (rating, required)
• Confidence Managing Condition at Home (rating, required)
• Were all medications explained? (multiple choice, required) — options: Yes, Mostly, Partially, No
• Do you have a follow-up appointment scheduled? (multiple choice, required) — options: Yes, No, Being Arranged
• Support Available at Home (checkboxes, optional) — options: Family, Professional Caregiver, Community Services, Home Health Nurse, None
• Overall Hospital Care Satisfaction (rating, required)
• What additional support do you need? (long text, optional)