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 DOB ID #
Where will patient be at discharge:
Address at patients location
Phone #
Discharging Facility:
Name of Discharging Facility Facility DC Planner Patient Anticipated DC Date Prior living situation
____ 2 Story ____ #Steps within Home OT OT ____Ranch ____ Bed/Bath Level Community Resources: ______________________________ Acute Hospital Care Other
Facility Admit Date Phone #
Discharge to (Check all that apply):
Home:
____ Multilevel ____ # Steps to Enter
Circle: PT Circle: PT
Home Health Agency Outpatient Assisted Living Long Term Care
Hospice Group Home
ST RN Other ST RN Other Acute Rehab Center LTAC
Facility / Home Care Agency (HCA) / Hospice Name Name of Home Care Agency Case Manager Phone #
Phone # Date of first HCA visit
Durable Medical Equipment
Preferred DME Provider
Contact name
Phone #
Wheel Chair Walker (type) _______ Cane Reachers Sock Aid Ramp Elevated Toilet Seat Safety Rails Other None Required
Page 2 of 3
Patient Name DOB ID #
Significant Other Guardian Sibling Primary Caregiver Lives Alone Spouse Neighbor Information: Daughter/Son Other Family Friend Availability for Physical Assist:_________________________
Able to handle care needs
Caregiver Name Address City
Phone # State Zip
Relationship to Patient/ Family (Please choose from options Lives Alone Spouse Significant Other Guardian Sibling Able to handle care needs
Additional Caregiver Daughter/Son Other Family Friend Neighbor Information: Availability for Physical Assist:_________________________
Caregiver Name Address City
Phone # 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?
Describe needs: Is Patient Safe to return home?
Confused Yes Yes
Agitated No No Assist
Current Patient Activity Level:
Independent
Minimal Assist Moderate
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 DOB ID #
Power of Attorney Information:
Durable Power of Attorney Durable Power of Attorney/ Health Care Attorney DPOA Name DPOA/HC Name
Phone # Phone #
Financial Planning:
Medicaid Disability Application Private Pay Adult Protective Services Other
Secondary Insurance
Follow Up Doctor Appointment:
Prior to discharge please schedule a follow up doctor appointment for within 30 days of discharge.
Physician Name Physician Address Transportation Plans
Appointment Date/ Time Office Phone #
Are there any barriers to patient following up with appointment? Yes No Please describe:______________________________________________________
No Change No Change No Change
Date Date Date RN/ Social Worker Signature RN/ Social Worker Signature RN/ Social Worker Signature
