Rehabilitation Discharge Checklist
Use this checklist to confirm discharge readiness, review instructions, and record support needs after rehabilitation care.
Patient and Discharge Details
Patient Name
*
First Name
Last Name
Date of Discharge
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Rehabilitation Program / Type
*
Inpatient Rehabilitation
Outpatient Rehabilitation
Home-Based Rehabilitation
Day Rehabilitation
Other
Primary Diagnosis / Reason for Rehab Discharge
*
Attending Clinician / Discharge Coordinator
First Name
Middle Name
Last Name
Preferred Contact Method for Follow-up
*
Phone
Email
Text Message
Postal Mail
Other
Functional Status and Clinical Readiness
Current mobility status
*
Independent
Supervised
Assisted
Unable to ambulate
Activities of daily living currently affected
*
Bathing
Dressing
Toileting
Transfers
Meal preparation
Medication management
Other
Pain or symptom level
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Overall readiness for discharge
*
Ready for discharge
Needs ongoing assistance
Not yet ready for discharge
Medication and Treatment Understanding
Were discharge medications and treatment instructions reviewed with the patient?
*
Yes
No
Does the patient understand how and when to take the medications as directed?
*
Yes
No
Medication questions or barriers to following the treatment plan
Were printed discharge instructions provided?
*
Yes
No
Equipment, Home Support, and Safety
Assistive devices or rehabilitation equipment needed at discharge?
*
Yes
No
Which equipment or devices are needed?
Walker
Wheelchair
Cane
Crutches
Shower chair
Grab bars
Raised toilet seat
Other
Is home support or caregiver assistance available?
*
Yes
No
Any home environment safety concerns?
Stairs without railings
Clutter or trip hazards
Poor lighting
Bathroom access concerns
Narrow doorways
Pet-related hazards
No concerns
Other
Transportation or mobility assistance arranged for discharge
Follow-up Plan and Final Discharge Acknowledgment
Follow-up Appointment or Referral Details
*
Destination After Discharge
*
Please Select
Home
Family Member's Home
Assisted Living
Skilled Nursing Facility
Rehabilitation Facility
Other
Outstanding Concerns or Unresolved Issues
Submit Checklist
Should be Empty: