1

Your 

Discharge 

Planning 

Checklist:

For patients and their caregivers 

preparing to leave a hospital, nursing home, 

or other care setting
Name:

Reason for admission: 

2

During your stay, your doctor and the staff will work with you to plan for 

your discharge. You and your caregiver (a family member or friend who may 

be helping you) are important members of the planning team. You and your 

caregiver can use this checklist to prepare for discharge.

Instructions: 

• Use this checklist early and often during your stay. 

• Talk to your doctor and the staff (like a discharge planner, social worker, or nurse) 

about the items on this checklist.

• Check the box next to each item when you and your caregiver complete it.

• Use the notes column to write down important information 

(like names and phone numbers).

• Skip any items that don’t apply to you.

What’s ahead?

 Ask where you’ll get care after you leave (after you’re 

discharged). Do you have options (like home health 

care)? Be sure you tell the staff what you prefer. 

 If a caregiver will be helping you after discharge, 

write down their name and phone number.

Your health

 Ask the staff about your health condition and what 

you can do to help yourself get better.

 Ask about problems to watch for and what to do 

about them. Write down a name and phone number 

of a person to call if you have problems.

 Action items Notes
 retarded retarded

 Use “My drug list”on page 5 to write down your 

prescription drugs, over-the-counter drugs, vitamins, 

and herbal supplements. 

 Review the list with the staff. 

 Tell the staff what drugs, vitamins, or supplements 

you took before you were admitted. Ask if you 

should still take these after you leave. 

 Write down a name and phone number of a person 

to call if you have questions. 

Recovery & support

 Ask if you’ll need medical equipment (like a walker). 

Who will arrange for this? Write down a name and 

phone number of a person you can call if you have 

questions about equipment.

 Ask if you’re ready to do the activities below. Circle 

the ones you need help with, and tell the staff: 

• Bathing, dressing, using the bathroom, climbing stairs

• Cooking, food shopping, house cleaning, paying bills

• Getting to doctors’ appointments, picking up 

prescription drugs

 Make sure you have support (like a caregiver) in place 

that can help you. See “Resources” on page 6 for more 

information.

 Ask the staff to show you and your caregiver any 

other tasks that require special skills (like changing 

a bandage or giving a shot). Then, show them you 

can do these tasks. Write down a name and phone 

number of a person you can call if you need help. 

 Ask to speak to a social worker if you’re concerned 

about how you and your family are coping with your 

illness. Write down information about support groups 

and other resources. 

 Talk to a social worker or your health plan if you 

have questions about what your insurance will cover, 

and how much you’ll have to pay. Ask about possible 

ways to get help with your costs.

 Action items Notes

3
 Ask for written discharge instructions (that you can read 

and understand) and a summary of your current health 

status. Bring this information and your completed “My 

drug list” to your follow-up appointments.

 Use “My appointments” on page 5 to write down 

any appointments and tests you’ll need in the next 

several weeks. 

For the caregiver

 Do you have any questions about the items on this 

checklist or on the discharge instructions? Write 

them down, and discuss them with the staff.

 Can you give the patient the help he or she needs? 

 What tasks do you need help with? 

 Do you need any education or training?

 Talk to the staff about getting the help you need 

before discharge.

 Write down a name and phone number of a person 

you can call if you have questions. 

 Get prescriptions and any special diet instructions early, 

so you won’t have to make extra trips after discharge.

 Action items Notes

If you need help choosing a home health agency or nursing home:

• Talk to the staff.

• Visit Medicare.gov to compare the quality of home health agencies, nursing homes, dialysis 

facilities, and hospitals in your area.

• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

If you think you’re being asked to leave a hospital or other health care setting (discharged) too soon:

You may have the right to ask for a review of the discharge decision by the Beneficiary and Family Centered Care 

Quality Improvement Organization (BFCC-QIO) before you leave. A BFCC-QIO is a type of quality improvement 

organization (a group of doctors and other health care experts under contract with Medicare) that reviews 

complaints and quality of care for people with Medicare. To get the phone number for your BFCC-QIO, visit 

Medicare.gov/contacts, or call 1-800-MEDICARE. You can also ask the staff for this information. If you’re 

in a hospital, the staff should give you a notice called “Important Message from Medicare,” which contains 

information on your BFCC-QIO. If you don’t get this notice, ask for it.

For more information on your right to appeal, visit Medicare.gov/appeals, or visit Medicare.gov/publications

to view the booklet “Medicare Appeals.”

4

More information for people with Medicare
My drug list Filled out on: _________________

Fill out this list with all prescription drugs, over-the-counter drugs, vitamins, and herbal supplements you 

take. Review this list with the staff.

If you have Medicare and limited income and resources, you may qualify for Extra Help to pay for 

your Medicare prescription drug coverage. For more information about Extra Help, visit Medicare.gov/

publications to view the booklet “Your Guide to Medicare Prescription Drug Coverage.”

APPOINTMENTS AND TESTS DATE PHONE NUMBER

5

DRUG NAME WHAT IT DOES DOSE HOW TO TAKE IT WHEN TO TAKE IT NOTES

 

Drug name What it does Dose How to take it When to take it Notes

My appointments

Appointments and tests Date Phone number
Resources 

The agencies listed here have information on community services, 

(like home-delivered meals and rides to appointments). You can 

also get help making long-term care decisions. Ask the staff in 

your health care setting for more information. 

Area Agencies on Aging (AAAs) and Aging and Disability Resource Centers (ADRCs): 

Help older adults, people with disabilities, and their caregivers. To find the AAA or ADRC in your area, 

visit the Eldercare Locator at eldercare.gov, or call 1-800-677-1116. 

Medicare: Provides information and support to caregivers of people with Medicare. Visit 

Medicare.gov/campaigns/caregiver/caregiver.html. 

Long-Term Care (LTC) Ombudsman Program: Advocate for and promote the rights of 

residents in LTC facilities. Visit ltcombudsman.org.

Senior Medicare Patrol (SMP) Programs: Work with seniors to protect themselves from 

the economic and health-related consequences of Medicare and Medicaid fraud, error, and 

abuse. To find a local SMP program, visit smpresource.org.

Centers for Independent Living (CILs): Help people with disabilities live independently. 

For a state-by-state directory of CILs, visit ilru.org/html/publications/directory/index.html.

State Technology Assistance Project: Has information on medical equipment and other 

assistive technology. Visit resna.org, or call 1-703-524-6686 to get the contact information in 

your state.

National Long-Term Care Clearinghouse: Provides information and resources to plan for 

your long-term care needs. Visit longtermcare.gov.

National Council on Aging: Provides information about programs that help pay for 

prescription drugs, utility bills, meals, health care, and more. Visit benefitscheckup.org.

State Health Insurance Assistance Programs (SHIPs): Offer counseling on health 

insurance and programs for people with limited income. Also help with claims, billing, and 

appeals. Visit Medicare.gov/contacts, or call 1-800-MEDICARE (1-800-633-4227) to get your 

SHIP’s phone number. TTY users should call 1-877-486-2048.

State Medical Assistance (Medicaid) Office: Provides information about Medicaid. To find 

your local office, visit Medicare.gov/contacts, or call 1-800-MEDICARE.

 

CMS Product No. 11376

Revised August 2014 

The information in this booklet describes the Medicare program at the time this booklet was printed. Changes may occur after printing. Visit 

Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227) to get the most current information. TTY users should call 1-877-486-2048.

“Your Discharge Planning Checklist” isn’t a legal document. Official Medicare Program legal guidance is contained in the relevant 

statutes, regulations, and rulings.