Discharge Planning Note (Hospital Case Management)

Note Type: [Initial Discharge Planning Evaluation / Follow-up Discharge Planning / Day-of-Discharge Finalization]

Patient/Encounter: [patient identifiers per policy, encounter type, unit/service]

Author: [role/discipline, date and time of note]

Contact(s) This Note: [date/time and method of patient/caregiver contact documented herein]

Reason for CM Involvement

[Brief trigger, referral source, or change prompting today's discharge planning activity] (Limit to 1–3 lines. Omit in follow-up notes if unchanged from prior note.)

Discharge Planning Evaluation

[Decision-maker and capacity: patient's capacity to participate; if representative involved, include name, relationship, and reason; interpreter use if applicable]

[Patient goals and preferences: desired discharge destination, priorities, and constraints such as stairs, caregiver availability, transportation, or financial considerations]

[Functional status: baseline living situation and assistance level versus current status per PT/OT/SLP; include mobility, ADLs, cognition as relevant]

[Clinical needs driving level-of-care: skilled nursing, therapy intensity, wound/IV needs, safety monitoring, follow-up requirements as applicable]

(Keep patient-specific and concise; omit non-applicable categories. If required information is unavailable, state "unable to assess" with reason and reassessment timeframe.)

Level of Care Recommendation & Patient Choice

Recommended Disposition: [Home (no services) / Home with services / SNF / IRF / LTCH / Hospice / Other]

[Brief clinical rationale linking patient needs to setting capabilities; note alternatives considered if applicable]

Choice Documentation: [Recipient of options list (patient/representative); confirm list of Medicare-participating providers for applicable service type was presented; patient/representative selection and priority ranking if multiple referrals] (If preferred provider unavailable, document reason and accepted alternative. Use explicit language confirming list was presented and patient made selection per CMS requirements.)

Arrangements

[Referrals and acceptance status: recipient, service type, date/time sent, current status; if accepted, include accepting facility/clinician and confirmation source]

[Authorization status: payer, reference number, decision if available; source of confirmation]

[Services and equipment arranged: home health disciplines and anticipated SOC; DME items, vendor, delivery timing; other services as applicable]

[Transportation: mode, pickup time, destination, medical necessity and authorization if required]

(Omit categories that do not apply. Do not document acceptance, authorization, or arrangements without verifiable confirmation and source.)

Barriers & Next Steps

[Active barriers: for each, include brief description, actions taken, current status, next step, owner, and expected timeline] (If barriers recently resolved, note resolution enabling discharge to proceed.)

EDD: [anticipated discharge date] — Contingent on: [what must occur to meet EDD]

Next CM Action: [specific task and timeframe]

Closing

Patient/Representative Agreement: [agrees / declines / undecided] (If declines, document risks discussed, mitigation steps, and escalation if initiated.)

[Signature/authentication per policy]