Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Discharge Survey
Your information
Patient Name *
Discharge Date
____ / ____ / ________
Discharge Instruction Clarity
- Very clear
- Mostly clear
- Somewhat unclear
- Not clear
- Not applicable
Medication Understanding
- Very clear
- Mostly clear
- Somewhat unclear
- Not clear
- Not applicable
Follow-Up Plan Clarity
- Very clear
- Mostly clear
- Somewhat unclear
- Not clear
- Not applicable
Warning Signs Explained
- Yes
- No
- Not sure
- Not applicable
Additional details
Caregiver Included in Education
- Yes
- No
- Not sure
- Not applicable
Readiness to Manage Care at Home
- Yes
- No
- Not sure
- Not applicable
Knows Whom to Contact
- Yes
- No
- Not sure
- Not applicable
Activity Restrictions Understood
- Yes
- No
- Not sure
- Not applicable
Overall Discharge Experience
- Excellent
- Good
- Fair
- Poor
- Very poor
- Not applicable
Additional Feedback
Discharge Survey template from formisoft.com. formisoft.com/intake-templates/discharge-survey