Projected length of stay (hours/days):________________________
Anticipated date of discharge:_______________________________
Date information obtained:________________________________ Source:________________________________________
Resources available: Persons:________ Financial:________ Community supports:________ Groups:________
Areas that may require alteration/assistance: Food preparation:_____ Shopping:_____ Transportation:_____ Ambulation:_____
Self-care (specify):________________________________ Socialization:________________________________
Medication/IV therapy:________________ Treatments:________________ Wound care:________________ Supplies:________________
Homemaker/maintenance(specify):________________________
Physical layout of home (specify):________________________
Anticipated changes in living situation after discharge:________________
Living facility other than home (specify):________________
Referrals (date/source/services): Social services:________________________ Rehabilitation:________________________
Dietary:________ Home care:________ Resp/O2:________ Equipment:________ Supplies:________ Other:________
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