Doctor Visit Checkout Checklist
Complete this checklist to ensure all steps are covered before concluding the doctor's visit.
Patient Full Name
*
First Name
Last Name
Date of Visit
*
-
Month
-
Day
Year
Date
Doctor's Name
*
Reason for Visit / Chief Complaint
*
Were all prescribed medications reviewed and explained to the patient?
*
Yes
No
Has the patient received written and verbal discharge instructions?
*
Yes
No
Follow-up appointment scheduled?
*
Yes
No
If yes, enter follow-up appointment date (if applicable)
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Checklist: Please confirm the following were completed during this visit.
*
Patient's questions answered
Patient understands medication instructions
Patient understands next steps for care
Patient provided with educational materials
Patient contact information verified
Other
Additional Notes (if any)
Submit Checklist
Should be Empty: