High-Risk Discharge Planning Form
Use this form to document and plan safe discharge procedures following a high-risk situation.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Discharge Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Contact Email
example@example.com
Reason for High-Risk Discharge
*
Current Status at Discharge
*
Please Select
Stable
Requires Monitoring
Needs Immediate Support
Other
Support Services Arranged
Home Care
Community Outreach
Follow-up Appointment
Transportation
Other
Discharge Action Plan
*
Responsible Staff Member
*
Additional Notes or Instructions
Submit
Should be Empty: