Discharge Nursing Note (Instructions & Readiness)

Date/Time: [Documentation date/time] Author: [Name, RN credentials] Unit/Service: [Unit/Service] Discharge Date/Time: [Planned date/time; actual date/time if different]

Discharge Plan

• Discharge destination: [home without services / home with services / SNF / IRF / LTACH / hospice / other facility] [Destination name if applicable]
• Primary learner(s): [patient / caregiver / both] [Name(s) and relationship(s)]
• Decision-making capacity/legal status: [Guardian / healthcare proxy / other; name and contact] (Include only if non-standard)
• Critical social factors impacting teaching: [Factors directly affecting instruction delivery] (Include only if present)

Communication & Learning Needs

(If standard English-speaking patient with no barriers, a single line confirming no special needs identified is sufficient.)

• Preferred language (spoken/written): [Language]
• Interpreter services: [none / in-person / video / phone]; materials provided in preferred language: [yes / no / N/A]
• Barriers to learning: [none identified / cognitive impairment / low health literacy / vision deficit / hearing deficit / severe pain or anxiety / other]
• Accommodations provided: [Large print / pictograms / caregiver-focused teaching / demonstration methods / quiet environment / other] (List only those used)

Discharge Education Delivered

Instruction packet/materials: [printed / electronic / both] provided and reviewed with [patient / caregiver / both]. (If declined, document refusal and what was offered.)

(Group related topics logically. Focus on education tied to discharge problems/conditions.)

• Condition overview & changes since admission: [Plain-language summary of condition(s) and what changed]
• Self-care tasks: [Home monitoring parameters, symptom tracking, other self-management instructions]
• Activity & safety: [Activity level, mobility aids, fall precautions, driving/work/lifting restrictions]
• Diet & nutrition: [Diet type, implementation guidance, fluid or sodium restrictions if applicable]
• Wound/line/drain/device care: [Steps, frequency, supplies, skin care, output measurement if applicable] (Include only if applicable)
• Pain management education: [Non-pharmacologic strategies, medication timing, sedation precautions, constipation prevention, safe opioid storage] (Include only if applicable)

Understanding Assessment: [teach-back / return demonstration / question prompts] used.

• [Specific item verified with method, e.g., patient accurately stated activity restrictions in own words]
• [Specific item verified]
• [Specific item verified]

(Document at least 2–3 specific items correctly explained or demonstrated. Do not document only "verbalized understanding.")

Medication Teaching

Medication reconciliation and review completed with: [patient / caregiver / both]. Written medication list provided.

• New medications: [Medication name, purpose, how/when to take] or "None"
• Stopped medications: [Medication name] or "None"
• Changed medications: [Medication name, what changed (dose/frequency/route)] or "None"
• High-risk medication counseling: [Medication category] — [Indication, dosing, key side effects, monitoring, actions to take] (Include for anticoagulants, insulin, opioids, anticonvulsants, immunosuppressants)
• Pharmacy plan: [eRx sent to pharmacy name / bedside delivery / pickup arranged / delivery arranged]; barriers and mitigation: [Cost or transportation issues and steps taken, or "none identified"]
• Medication understanding assessment: Teach-back completed on [highest-risk medication]; verified [specific points confirmed, e.g., dosing schedule, missed dose plan, side effects to watch for]

(If no discharge medications prescribed, state "No discharge medications prescribed" and omit above details.)

Equipment & Home Services

(Include this section only when DME, supplies, or post-discharge services were arranged.)

• DME/supplies: [Item] — status: [ordered / delivered to bedside / delivered to home / pending]; vendor: [Name/contact]; training with return demonstration: [completed / not required]
• Home services: [Home health nursing / PT / OT / ST / hospice / infusion] — referral status: [sent / accepted / pending]; expected first visit: [Timeframe if known]
• Transportation services: [Ambulance / wheelchair van / rideshare / family] — [Arrangement details] (Include only if arranged)
• Pending items: [What is pending, who will contact patient, expected timeframe, number to call if not contacted]

Follow-up Plan

• PCP: [Provider name, scheduled date/time/location] or "To be scheduled by [patient / clinic]"
• Specialty/therapy: [Provider/clinic, date/time or scheduling plan]
• Labs/imaging: [Test, location, timeframe] or "None scheduled"
• Pending results: [Test name] — [Responsible provider/clinic] will follow up [Method and timeframe] (Include only if results pending)
• Contact information: [Clinic numbers and after-hours guidance as provided in discharge materials]

Warning Signs & When to Seek Care

(Base on discharge problems/conditions. Pair each warning sign category with the corresponding action.)

• Warning signs discussed: [Condition-specific red flags, e.g., wound infection signs, weight gain/SOB for HF, neurologic changes]
• Actions for each: [Call clinic / use nurse advice line / go to ED / call 911] matched to above scenarios
• Understanding assessment: Patient/caregiver correctly identified [at least 2–3 specific red flags and corresponding actions]

Caregiver Training

(Include this section only when a caregiver participated in education or is required for safe discharge.)

• Caregiver: [Name, relationship] — participation: [in person / phone / video]
• Topics taught: [Skills and knowledge areas covered]
• Return demonstration: [Skills demonstrated and accuracy]
• If caregiver unavailable: [Attempts made, interim plan, provider/case management notification] (Include only if caregiver unavailable but required)

Discharge Readiness & Departure

(Use objective statements within nursing scope.)

• Pain: [Controlled to patient goal of X/10 / not at goal] — [Current level and interventions]
• Nausea/GI: [Controlled / uncontrolled]; oral intake: [Tolerating / limited]
• Mobility/safety: [Objective specifics, e.g., ambulated X feet with walker, standby assist; safe transfers demonstrated]
• Mental status: [At baseline / improved / stable] relative to admission baseline
• Lines/drains/devices: [All removed / remained in place: (type), teaching completed]
• Safety tasks completed: [IV removed, telemetry discontinued, belongings returned, fall precautions reviewed]
• Patient-stated readiness: "[Brief quote or summary]"
• Remaining risks/barriers and mitigation: [Medication access, transportation, fall risk, caregiver coverage, and steps taken] or "None identified"

Departure: [Actual departure time]; mode: [ambulatory / wheelchair / stretcher]; accompanied by: [Staff name / family member / EMS]; destination confirmed: [yes / no]

Materials provided at departure: [Discharge packet, prescription/eRx confirmation, equipment, supplies]

Exceptions or Refusals

(Include this section only when applicable.)

• Refusals: [What was refused: teaching / materials / medications / equipment]; alternatives offered: [What was offered]; education provided despite refusal: [What was still communicated]
• Patient unable to participate: [Reason]; caregiver education: [Completed / not completed / no caregiver available]
• Notifications: [Provider and/or case management notified, time]

(For AMA or elopement, reference separate facility documentation per workflow.)

Nurse Signature: [Name, credentials] Date/Time: [Authentication timestamp]

(If nursing student participated, identify supervising RN.)