Patient Discharge Readiness Quiz Form
Complete this quiz to assess if a patient is ready for discharge. Please answer all questions based on your evaluation.
Patient Name
*
First Name
Last Name
Patient ID Reference (Internal Non-Sensitive Identifier)
*
Discharge Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Overall Discharge Readiness Rating
*
1
2
3
4
5
Is the patient able to understand discharge instructions?
*
Yes
No
Partially
Does the patient understand their medication regimen?
*
Yes
No
Needs further explanation
Has a follow-up appointment been scheduled?
*
Yes
No
Not required
Is transportation and/or home support arranged for the patient?
*
Transportation arranged
Home support arranged
Not needed
Other
Are there any concerns before discharge?
Staff Notes
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