Colostomy Care Discharge Education Form
Please complete this form to document and confirm key topics covered during colostomy care discharge education.
Patient Name
*
First Name
Last Name
Date of Education
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Educator Name
*
First Name
Last Name
Colostomy Care Topics Covered
*
Stoma site care
Changing and emptying the pouch
Recognizing signs of infection or complications
Diet and hydration guidance
Supplies and ordering information
Lifestyle and activity recommendations
When to contact a healthcare provider
Other
Please rate your understanding of colostomy care after this education session.
*
1
2
3
4
5
Do you have any questions or concerns about your colostomy care?
Additional notes or recommendations
Submit
Should be Empty: