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Inpatient Discharge Planning Questionnaire - Free Healthcare Template | ZenBuild | ZenBuild

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Inpatient Discharge Planning Questionnaire

Gather information from patients and families to plan safe and appropriate hospital discharge.

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Inpatient Discharge Planning Questionnaire

Gather information from patients and families to plan safe and appropriate hospital discharge.

Patient Name*

Admission Date*

Primary Diagnosis*

Primary Care Physician

Living situation upon discharge*

AloneWith family or caregiverAssisted livingNursing facilityHomeless or unstable housing

Do you have a caregiver at home who can assist with recovery?*

YesNoUncertain

Anticipated Discharge Needs

Home health aidePhysical or occupational therapyWound careMedication managementMedical equipmentTransportationMeals on Wheels

Concerns about going home

Emergency Contact Name and Relationship*

Template Details

CategoryHealthcare

IndustryHealthcare

Fields9

Uses0

Views1

discharge planninginpatientcare coordinationhospital