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 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 patient’s location
Phone #
Discharging Facility: Name of 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
□ Lives Alone □ Spouse □ Significant Other □ Guardian □ Sibling □ Daughter/Son □ Other Family □ Friend □ Neighbor Availability for Physical Assist:_________________________ □ Able to handle care needs
Caregiver Name
Phone #
Address
City
State
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 Psycho-Social and Mental Status:
Current Patient Activity Level:
□ Alert □ Oriented
□ Cooperative
□ Confused
□ Agitated
Depression Screen/Mini Mental? Describe needs:
□ Yes
□ No
Is Patient Safe to return home?
□ Yes
□ No
□ Independent
□ Moderate
□ Minimal Assist
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:____________________________________
