Stroke Discharge Planning Checklist Form
Complete this checklist to ensure all essential steps for stroke discharge readiness and follow-up are addressed.
Patient Full Name
*
First Name
Last Name
Date of Discharge
*
-
Month
-
Day
Year
Date
Mobility status and transfer needs reviewed
*
Independent
Needs assistance
Requires equipment
Discharge medications reviewed with patient/caregiver
*
Completed
Not applicable
Patient/caregiver received stroke education materials
*
Yes
No
Follow-up appointments scheduled
*
Yes
No
Home support and services arranged (e.g., home health, therapy)
*
Yes
No
Not needed
Equipment needs addressed (e.g., walker, wheelchair, adaptive devices)
*
Yes
No
Not needed
Dietary needs and restrictions reviewed
*
Completed
Not applicable
Additional notes or concerns
Submit Checklist
Should be Empty: