Ostomy Discharge Checklist Form
Complete this checklist to confirm patient and/or caregiver readiness for discharge and understanding of essential ostomy care instructions.
Patient Full Name
*
First Name
Last Name
Date of Surgery
*
 -
Month
 -
Day
Year
Date
Ostomy Type
*
Please Select
Colostomy
Ileostomy
Urostomy
Other
Stoma Assessment (color, size, condition)
*
Ostomy Appliance Fit and Function Assessed
*
Yes
No
Education Provided on Ostomy Care (emptying, cleaning, changing pouch)
*
Emptying pouch
Cleaning stoma and skin
Changing appliance
Disposal of supplies
Other
Supplies Provided and Understood
*
Yes
No
Warning Signs Reviewed (leakage, infection, skin problems, blockage)
*
Yes
No
Follow-Up Appointment Arranged
*
Yes
No
Patient and/or Caregiver Demonstrated Readiness for Discharge and Understanding of Ostomy Care
*
I confirm that I understand the ostomy care instructions and am ready for discharge.
Submit Checklist
Should be Empty: