Skilled Discharge Planning Form

Instructions: Discharge Planning begins on the first day of patient /resident admission. Please complete and fax this form beginning with admission and with each update thru discharge. If no change occurs by discharge, resubmit with a signature and date at the bottom of the second page, indicating no change

Patient Information:
Patient Name DOB ID #

Where will patient be at discharge:

Address at patients location

Phone #

Discharging Facility:
Name of Discharging Facility Facility DC Planner Patient Anticipated DC Date Prior living situation
____ 2 Story ____ #Steps within Home OT OT ____Ranch ____ Bed/Bath Level Community Resources: ______________________________ Acute Hospital Care Other

Facility Admit Date Phone #

Discharge to (Check all that apply):

Home:

____ Multilevel ____ # Steps to Enter

Circle: PT Circle: PT

Home Health Agency Outpatient Assisted Living Long Term Care

Hospice Group Home

ST RN Other ST RN Other Acute Rehab Center LTAC

Facility / Home Care Agency (HCA) / Hospice Name Name of Home Care Agency Case Manager Phone #

Phone # Date of first HCA visit

Durable Medical Equipment

Preferred DME Provider

Contact name

Phone #

Wheel Chair Walker (type) _______ Cane Reachers Sock Aid Ramp Elevated Toilet Seat Safety Rails Other None Required

Page 2 of 3
Patient Name DOB ID #

Significant Other Guardian Sibling Primary Caregiver Lives Alone Spouse Neighbor Information: Daughter/Son Other Family Friend Availability for Physical Assist:_________________________

Able to handle care needs

Caregiver Name Address City

Phone # State Zip

Relationship to Patient/ Family (Please choose from options Lives Alone Spouse Significant Other Guardian Sibling Able to handle care needs

Additional Caregiver Daughter/Son Other Family Friend Neighbor Information: Availability for Physical Assist:_________________________
Caregiver Name Address City

Phone # State Zip

Relationship to Patient/ Family (Please choose from options

Family Support Contact:

Support Contact Name

Phone #

Relationship to Patient/ Family (Please choose from options

Are there any caregiver issues that we should be aware of to better assist patient? Yes No If yes, please describe below:

Current Patient Alert Oriented Cooperative Psycho-Social and Mental Status: Depression Screen/Mini Mental?
Describe needs: Is Patient Safe to return home?

Confused Yes Yes

Agitated No No Assist

Current Patient Activity Level:

Independent

Minimal Assist Moderate

Full Assist

Transportation Are there any transportation needs? Yes No Needs: Describe:

If yes, type of transportation needed: Ambulance Ambulette Automobile Name of Transportation Provider:____________________________________

Page 3 of 3:
Patient Name DOB ID #

Power of Attorney Information:

Durable Power of Attorney Durable Power of Attorney/ Health Care Attorney DPOA Name DPOA/HC Name

Phone # Phone #

Financial Planning:

Medicaid Disability Application Private Pay Adult Protective Services Other

Secondary Insurance

Follow Up Doctor Appointment:

Prior to discharge please schedule a follow up doctor appointment for within 30 days of discharge.

Physician Name Physician Address Transportation Plans

Appointment Date/ Time Office Phone #

Are there any barriers to patient following up with appointment? Yes No Please describe:______________________________________________________

No Change No Change No Change

Date Date Date RN/ Social Worker Signature RN/ Social Worker Signature RN/ Social Worker Signature