Hospital Discharge Checklist Form
Please complete this checklist before discharge to ensure all necessary steps have been taken.
Patient Full Name
First Name
Last Name
Date of Discharge
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Discharge Instructions Provided
Yes
No
Not Applicable
Medications Reviewed and Provided
Yes
No
Not Applicable
Follow-up Appointment Scheduled
Yes
No
Not Applicable
Patient Education Completed
Yes
No
Not Applicable
Equipment and Supplies Provided
Yes
No
Not Applicable
Additional Notes
Discharge Nurse Signature
Submit
Should be Empty: