Skilled Discharge

Planning Form
Instructions: Discharge Planning begins on the first day of patient /resident admission. Please complete
and fax this form beginning with admission and with each update thru discharge. If no change occurs by
discharge, resubmit with a signature and date at the bottom of the second page, indicating no change

Patient Information:
Patient Name

Where will patient be

at discharge:

ID #

DOB

Address at patients location

Phone #

Discharging
Facility:
Name of Discharging Facility

Facility Admit Date

Facility DC Planner

Phone #

Patient Anticipated DC Date

Discharge to
(Check all that
apply):

Home:

____ Multilevel
____ # Steps to Enter

Home Health Agency

Outpatient
Assisted Living
Long Term Care

Circle: PT
Circle: PT

Prior living situation

____ 2 Story
____ #Steps within Home
OT
OT

Hospice
Group Home

____Ranch
____ Bed/Bath Level

ST
RN
Other
ST
RN
Other
Acute Rehab Center
LTAC

Facility / Home Care Agency (HCA) / Hospice Name

Name of Home Care Agency Case Manager

Durable Medical
Equipment

Preferred DME Provider

Phone #

Contact name

Community Resources:
______________________________
Acute Hospital Care
Other

Phone #
Date of first HCA visit

Phone #

Wheel Chair
Walker (type) _______ Cane
Reachers
Sock Aid
Ramp
Elevated Toilet Seat Safety Rails
Other None Required

Page 2 of 3
Patient Name

ID #

DOB

Significant Other Guardian Sibling

Primary Caregiver Lives Alone Spouse
Neighbor
Information: Daughter/Son Other Family Friend
Availability for Physical Assist:_________________________

Caregiver Name

Able to handle care needs

Phone #

Address

City

State

Zip

Relationship to Patient/ Family (Please choose from options

Lives Alone

Spouse

Significant Other

Guardian

Additional Caregiver Daughter/Son Other Family Friend

Neighbor
Information: Availability for Physical Assist:_________________________
Caregiver Name

Sibling
Able to handle care needs

Phone #

Address

City

State

Zip

Relationship to Patient/ Family (Please choose from options

Family Support
Contact:

Support Contact Name

Phone #

Relationship to Patient/ Family (Please choose from options

Are there any caregiver issues that we should be aware of to better assist patient?
Yes No If yes, please describe below:

Current Patient Alert Oriented Cooperative

Psycho-Social and
Mental Status: Depression Screen/Mini Mental?

Confused

Agitated

Yes

No

Yes

No

Describe needs:

Is Patient Safe to return home?

Current Patient
Activity Level:

Independent

Minimal Assist Moderate

Assist

Full Assist

Transportation Are there any transportation needs?

Yes
No
Needs: Describe:
If yes, type of transportation needed:
Ambulance
Ambulette Automobile
Name of Transportation Provider:____________________________________

Page 3 of 3:
Patient Name

Power of Attorney
Information:

ID #

DOB

Durable Power of Attorney

Phone #

Durable Power of Attorney/ Health Care Attorney

Phone #

DPOA Name
DPOA/HC Name

Financial Planning:

Follow Up Doctor
Appointment:

Medicaid
Disability Application Private Pay
Adult Protective Services Other

Secondary Insurance

Prior to discharge please schedule a follow up doctor appointment for within 30 days of discharge.

Physician Name

Appointment Date/ Time

Physician Address

Office Phone #

Transportation Plans

Are there any barriers to patient following up with appointment?

Yes
No
Please describe:______________________________________________________

No Change
No Change
No Change

Date

RN/ Social Worker Signature

Date

RN/ Social Worker Signature

Date

RN/ Social Worker Signature