Hospital Patient Discharge Process Improvement Checklist
Use this form to review discharge readiness, education, follow-up needs, and process improvement opportunities for a hospital patient discharge.
Discharge Review
Patient Name or Chart ID
*
Discharge Date
*
-
Month
-
Day
Year
Date
Discharge Department / Unit
*
Please Select
Emergency
Surgery
Internal Medicine
Pediatrics
Maternity
ICU
Rehabilitation
Other
Primary Diagnosis or Discharge Reason
*
Discharge Status / Readiness
*
Ready for discharge
Pending final review
Delayed
Escalated
Core Discharge Steps Completed
Medication and Care Instructions
Medication reconciliation completed
*
Yes
No
Discharge medications reviewed with patient or caregiver
*
Yes
No
Medication access concerns
Please Select
None
Cost concerns
Pharmacy availability
Transportation to pharmacy
Insurance coverage
Other
Follow-up instructions explained
*
Yes
No
Warning signs or red-flag symptoms reviewed
*
Yes
No
Special care instructions provided
Equipment, Support, and Follow-Up
Home medical equipment needed
Walker
Wheelchair
Hospital bed
Oxygen
Commode
Other
Home health or community support arranged?
*
Yes
No
If yes, please provide details
Follow-up appointment date and time
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Discharge destination
Please Select
Home
Rehabilitation facility
Skilled nursing facility
Assisted living
Other
Barriers to discharge identified
Transportation unavailable
Equipment not available
Caregiver unavailable
Insurance or coverage concerns
Home environment concerns
Clinical follow-up pending
Other
Additional services or referrals needed
Improvement Checklist and Feedback
What went well during the discharge process?
What caused delay or friction?
Communication handoff quality
Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
Patient/caregiver understanding of discharge instructions
Not at all clear
Somewhat clear
Mostly clear
Very clear
Other
Overall discharge process quality
1
2
3
4
5
Improvement suggestions
Submit
Should be Empty: