Care Transition Coordination Form

Care Transition Coordination Form — Form Fields

This healthcare template includes 14 fields. Discharge planners complete a structured handoff form to coordinate patient care transitions across settings. Free to customize and use on ZenBuild.

• Discharging Facility Name (text, required)
• Discharge Planner Name (text, required)
• Planner Email (email, required)
• Patient Full Name (text, required)
• Date of Birth (text, required)
• Diagnosis at Discharge (text, required)
• Discharge Date (text, required)
• Receiving Setting (dropdown selection, required) — options: Home, SNF, LTACH, Inpatient Rehab, Home Health, Outpatient, Assisted Living
• Receiving Provider or Facility Name (text, required)
• Follow-Up Appointment Scheduled? (dropdown selection, required) — options: Yes - Within 7 Days, Yes - Within 30 Days, No, Patient Declined
• Medication Reconciliation Complete? (dropdown selection, required) — options: Yes, Partial, No
• Patient education on red flags completed (checkboxes, required)
• Patient understands discharge instructions (checkboxes, required)
• Outstanding issues for receiving team (long text, optional)