Newborn Discharge Teaching Checklist Form
Review teaching topics, follow-up plans, and caregiver understanding.
Caregiver name
*
First Name
Last Name
Caregiver relationship to newborn
*
Please Select
Parent or guardian
Family member
Other caregiver
Newborn's first name
How ready do you feel to care for your newborn at home?
*
Not ready yet
1
2
3
4
Very ready
5
1 is Not ready yet, 5 is Very ready
Teaching topics reviewed
*
Feeding and feeding cues
Diapering and skin care
Safe sleep
When to contact the care team
Follow-up planning
Other teaching topic
Was the feeding plan reviewed with you?
*
Yes
Not yet
Was safe sleep guidance reviewed with you?
*
Yes
Not yet
Planned follow-up date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What questions or topics would you like to review further?
I understand the teaching reviewed and know how to seek further guidance if needed.
*
Yes, I understand
I would like more explanation
Submit checklist
Should be Empty: