DISCHARGE PLANNING TOOL
Name​: __________________________________________
Date​:_____________
DOB​: ___________ Admission Date:​ ________________
MoCA: _________ RIPA-G: _________ FLCI: ________
SLUMS: ________ MMSE: _________ BCAT: _______
Assistive devices: ​hearing aids / other assistive listening device / communication board
Dentures: ​natural / edentulous / poor dentition / dentures / upper / lower
Adaptive equipment: ​wheelchair / standard walker / two-wheeled walker / rollator walker
Precautions: ​oxygen dependent / NPO / aspiration precautions / modified diet:​______________
Discharge Plan (circle one)…
➢ Location: ​house / apartment / mobile home
➢ Lives: ​alone / with spouse / with family member (son, daughter, etc.) / with friend
➢ Assistance available: n
​ one / monthly/ weekly / daily
➢ Assistance from: ​spouse / family member / caregiver / home health
Patient can...
❏ State their name, address, and phone number independently
❏ Write their name, address, phone number independently
❏ State who to call in an emergency (911) and demonstrate use of primary phone
❏ State dietary restrictions independently (e.g., diabetic, cardiac, low sodium, etc.)
❏ State allergies independently
❏ State precautions independently
❏ Orient with use of a calendar, clock, or other aids
❏ Manage their medications independently, with or without use of pillbox, reminders, etc.
❏ Medi-Cog Score: ___________
❏ Informal medication management assessment: ________________________
❏ Demonstrate appropriate use and safety of adaptive equipment (example: sequencing
with brakes for walkers and wheelchairs, reasoning and safety situations, etc.)
❏ Demonstrate ability to maintain assistive devices (cleaning of dentures and/or hearing
aids, can plug in communication device/cell phone)
❏ Count money appropriately for cash transactions and give accurate change
❏ Fill out checks appropriately (accurate amounts, all portions completed and correct, etc.)
❏ Balance a checkbook with various types/amounts of transactions
❏ Follow a recipe, including gathering required ingredients, utensils, etc., setting timers
and oven temperature
❏ State solutions to common household problems and situations (tripped breaker/power
outage, grease fire, unknown phone calls/visitors, hazardous weather, etc.)
❏ Care for any household pets, including maintaining feeding and veterinary schedule
Additional comments:
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Created by: Nikki Fahrenthold, MS CF-SLP