Personal Safety Nets

For patients and their caregivers preparing to leave a hospital, nursing home, or other care setting

During your stay, your doctor and the staff will work with you to plan for your discharge. You and your caregiver(s) - family member or friend who may be helping you - are important members of the planning team.

Below is a checklist of important things you and your caregiver(s) should know to prepare for discharge. Use this checklist early and often during your stay. Talk to your doctor and the staff (which could be a discharge planner, social worker, or nurse) about the items on the checklist.

Use the notes column to write down important information (like names and phone numbers). Skip any items that don’t apply to you.

ACTION ITEMS NOTES

1. What’s Ahead?

• Ask where you will get care after discharge. 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.

2. 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 ________________________
  to call if you have problems.

• Use “My Drug List” (scroll down) 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 to call if you have questions. _______________________

3. Recovery and Support

• Ask if you will need medical equipment (like a walker). ________________________

• Who will arrange for this? Write down where to call if ________________________
  you have questions about equipment.

• Ask if you’re ready to do the activities listed 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.
  
  
• 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 to 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 will have to pay. Ask about
  possible ways to get help with your costs.

• 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” (scroll down) to write down any ________________________
  appointments and tests you will need in the next
  several weeks.

4. 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 to call if
  you have questions. ________________________
• Get prescriptions and any special diet instructions early, _______________________
  so you won’t have to make extra trips after discharge.

Now it's time to create and fill out a list with all prescription drugs, over-the-counter drugs, vitamins, and herbal supplements you take. Review this list with the staff.

MY DRUG LIST Filled out on: ____________________

Be sure to include:

Drug Name What it Does Dose How to take it When to take it Notes

____________________

Finally, make and create a list of future appointments.

MY APPOINTMENTS

Be sure to include:
Appointments & Tests
Date
Phone number

Adapted by Personal Safety Nets® from Medicare® Medicaid® and other sources.