Patient Discharge Benefits Delivery Checklist Form
Use this checklist to confirm that all discharge-related benefits and materials have been delivered to the patient before leaving care.
Patient Initials or Non-Sensitive ID
*
Date and Time of Discharge
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Recipient of Discharge Benefits
*
Patient
Family Member
Caregiver
Other
Checklist of Delivered Benefits and Materials
*
Discharge instructions provided
Medication list given
Follow-up appointment details shared
Personal belongings returned
Contact information for questions provided
Other
Were all items explained to the recipient?
*
Yes
No
Acknowledgment of Receipt
*
All items received and acknowledged
Some items declined
Other
Follow-up Instructions Given
*
Yes
No
Not Applicable
Additional Comments (if any)
Staff Member Completing Checklist
*
Date Checklist Completed
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Checklist
Should be Empty: