Patient Discharge Risk Assessment Form
Assess patient readiness and identify risk factors before discharge from care.
Physical Health Status at Discharge
*
Stable
Improved but not fully stable
Unstable
Cognitive/Mental Status
*
Alert and oriented
Mild confusion
Disoriented or confused
Mobility at Discharge
*
Independent
Requires assistance
Bedbound
Understanding of Medication Regimen
*
Understands completely
Partial understanding
Does not understand
Support System at Home
*
Strong support (family/caregiver present)
Limited support
No support
Risk of Readmission
*
Low
1
2
3
4
High
5
1 is Low, 5 is High
Ability to Perform Activities of Daily Living (ADLs)
*
Fully independent
Needs some assistance
Dependent on others
Home Environment Safety
*
Safe and accessible
Minor safety concerns
Unsafe
Follow-Up Appointment Arranged
*
Yes, with primary care
Yes, with specialist
No appointment arranged
Patient/Family Understanding of Discharge Instructions
*
Not at all
1
2
3
4
Completely
5
1 is Not at all, 5 is Completely
Submit Assessment
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