Discharge Survey
Survey

Discharge Survey

2 pages12 fieldsHIPAA-ready

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Discharge Survey
Patient Name
Discharge Date
Discharge Instruction Clarity
Medication Understanding
Follow-Up Plan Clarity
Warning Signs Explained
Caregiver Included in Education
Readiness to Manage Care at Home
Knows Whom to Contact
Activity Restrictions Understood
Overall Discharge Experience
Additional Feedback
Submit

The Discharge Survey gathers critical feedback from patients who are being discharged from a hospital, surgical center, or inpatient facility. The transition from inpatient to home care is one of the highest-risk moments in the patient journey, and understanding how well your discharge process prepares patients for self-management can directly reduce readmission rates. This template evaluates the clarity of discharge instructions, patient confidence in managing their condition at home, understanding of new medications, and awareness of warning signs that should prompt them to seek emergency care.

The survey covers the full discharge experience including how much advance notice the patient received, whether they felt rushed or had adequate time to ask questions, and whether a family member or caregiver was included in the discharge education. Patients rate the quality of written discharge instructions, their understanding of activity restrictions and dietary guidelines, wound care instructions if applicable, and the plan for follow-up appointments. A dedicated section assesses whether the patient knows whom to call if they have questions or concerns after leaving the facility.

Designed for hospitals, ambulatory surgery centers, rehabilitation facilities, and skilled nursing facilities, this survey supports compliance with CMS discharge planning requirements and HCAHPS survey domains. The data helps discharge planners, case managers, and nursing leadership identify where education gaps exist and implement targeted interventions to improve patient preparedness, reduce preventable readmissions, and strengthen the overall care transition process.

What's included

  • Discharge instruction clarity and comprehension assessment
  • Medication understanding and reconciliation verification
  • Follow-up appointment and care plan awareness evaluation
  • Warning sign education and emergency contact confirmation
  • Caregiver involvement and home readiness assessment
  • Overall discharge experience rating with open feedback

Who uses this template

  • Hospitals reducing 30-day readmission rates through discharge feedback
  • Ambulatory surgery centers evaluating post-operative discharge education
  • Rehabilitation facilities assessing patient readiness for home transition
  • Case managers identifying gaps in discharge planning processes

All form fields

12 fields across 2 pages. Customize any field after signing up.

Patient NameText
Discharge DateDate
Discharge Instruction ClarityMultiple Choice
Medication UnderstandingMultiple Choice
Follow-Up Plan ClarityMultiple Choice
Warning Signs ExplainedMultiple Choice
Caregiver Included in EducationMultiple Choice
Readiness to Manage Care at HomeMultiple Choice
Knows Whom to ContactMultiple Choice
Activity Restrictions UnderstoodMultiple Choice
Overall Discharge ExperienceMultiple Choice
Additional FeedbackLong Text

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