The document describes a discharge plan template for a baccalaureate graduate nurse. The template includes sections for assessment, diagnosis/plan, education needs, and a financial worksheet. The assessment section collects information on the patient's medical history, current condition, medications, functional status, support system, and follow up needs. The diagnosis/plan section identifies priorities, nursing diagnoses, and goals. The education needs section outlines topics, teaching methods, and how learning will be evaluated. The financial worksheet calculates the costs of ongoing medical care, medications, supplies, testing, equipment, transportation, home adaptations, complications, and totals costs.

1. Collaboration for Improving Outcomes – Discharge Plan
Description: The baccalaureate graduate nurse will conduct a
health history to identify
current and future health problems.
Course Competencies: 2) Develop a holistic case management
plan for a specified disease or
population that incorporates the role of insurance, health care
finance, and utilization of
community resources. 4) Coordinate the care of individuals
across the lifespan utilizing
principles and knowledge of interdisciplinary models of care
delivery and case management.
QSEN Competencies: 1) Patient-Centered Care 2) Teamwork
and Collaboration 3) Evidence-
Based Practice
BSN Essential VII
Area Gold
Mastery
Silver

2. Proficient
Bronze
Acceptable
Acceptable
Mastery not
Demonstrated
Assessment
• General
Information
• Current
Medications
• Activity of
Daily Living
• Patient Support
System
• Medical
Follow-up
• Financial
Summary
Completes all
sections of the

3. assessment
Completes half
of the elements
of the
assessment.
Completes
less than half
of the
elements of
the
assessment
Elements are
superficially
addressed or
are missing.
Diagnosis/Plan
• Priority
• Nursing
Diagnosis

4. • Client
Outcomes/Goals
Completes all
elements of the
diagnosis/plan
Completes half
of the elements
of the
diagnosis/plan
Completes
less than half
of the
elements of
the
diagnosis/plan
Elements are
superficially
addressed or

5. are missing.
Education Needs
• Need
• Method
• Evaluation
Completes all
elements of the
education
needs
Completes half
of the elements
of the
education
needs
Completes
less than half
of the
elements of

6. the education
needs
Elements are
superficially
addressed or
are missing.
Financial Worksheet
• Future Medical
Care
-routine
-specialty
-Tx
interventions
• Medication
Needs

7. • Supplies
• Diagnostic
Testing
• Future
Adjunctive Tx
• Medical
Equipment
• Transportation
• Home
Furnishings &
Adaptations
• Potential
Complications
• Financial
Summary
Completes all
elements of the
financial
worksheet
Completes half
of the elements

8. of the financial
worksheet
Completes
less than half
of the
elements of
the financial
worksheet
Elements are
superficially
addressed or
are missing.
Reflection and
Conclusion
Interprets the
complete
format and

9. develops a
conclusion for
the plan of care
Reviews the
format and
does not fully
develop a
conclusion for
the plan of care
Defines the
format and
does not
present a
conclusion
Does not
provide an
interpretation
of the format

10. and/or no
conclusion for
plan of care.
APA, Grammar,
Spelling, and
Punctuation
No errors in
APA, Spelling,
and
Punctuation.
One to three
errors in APA,
Spelling, and
Punctuation.
Four to six
errors in
APA,
Spelling, and

11. Punctuation.
Seven or more
errors in APA,
Spelling, and
Punctuation.
References Provides two or
more
references.
Provides two
references.
Provides one
references.
Provides no
references.
I. ASSESSMENT
Name: Click here to enter text.
DOB: XX/XX/XXXX
Date of Admission: Click here to enter a date.

12. Assessment Date: Click here to enter a date.
Admitting Diagnosis: Click here to enter text.
Past Medical History (include surgical history)
Click here to enter text.
Subjective history of current hospitalization (what led to current
hospitalization?)
Family and social history
Click here to enter text.
Summary of physical assessment (complete head-to-toe from
hospitalization documentation)
Click here to enter text.
Allergies: Click here to enter text.
Effects of diagnosis on daily living: Click here to enter text.
Current Medications (to add rows, click “insert row” on Table
Layout tools)
Name
Dose
Schedule
Last taken

13. Activity of Daily Living and Instrumental Activity of Daily
Living Assessment (Place an “X” in the appropriate column)
Activity
Not applicable
Dependent
Semi
Independent
Bathing
Dressing
Personal Cares

14. Continence
Toileting
Transferring
Ambulation
Climbing Stairs
Eating
Shopping

15. Food Preparation
Managing Medications
Using the Phone
Housework
Laundry
Transportation
Managing Finances
Total

16. Patient Support System (based upon above assessment, who is
available to provide care or support to patient)
Name
Relationship
AvailabilityClick here to enter text.Click here to enter
text.Click here to enter text.Click here to enter text.Click here
to enter text.Click here to enter text.Click here to enter
text.Click here to enter text.Click here to enter text.
Medical Follow-upClick here to enter text.
Financial SummaryClick here to enter text.
II. DIAGNOSIS/PLAN
List your top three priorities, create a nursing diagnosis, and
create two goals for each
Priority
1. Click here to enter text.
2. Click here to enter text.
3. Click here to enter text.
Nursing diagnosisClick here to enter text.Click here to enter
text.Click here to enter text.
Client outcomes
1. Click here to enter text.
1. Click here to enter text.
1. Click here to enter text.
2. Click here to enter text.

17. 2, Click here to enter text.
2. Click here to enter text.
III. EDUCATION NEEDS
Need
Method
Evaluation of learningClick here to enter text.Click here to
enter text.Click here to enter text.Click here to enter text.Click
here to enter text.Click here to enter text.
I. Future Medical Care - Routine
Routine Care Description
Frequency of visits
Purpose
Cost per visit
Cost per year
IV. FINANCIAL WORKSHEET
Subtotal
II. Future Medical Care - Specialty
Description
Frequency

18. Purpose
Cost per visit
Cost per year
Subtotal
III. Future Medical Care – Treatment Interventions
Recommendation
Frequency of procedure
Purpose
Cost per procedure
Cost per year

19. Subtotal
IV. Medication Needs
Name/dose
Schedule
Purpose
Cost per month
Cost per year
Subtotal
V. Supplies
Supplies
Schedule
Purpose
Cost per month
Cost per year

20. Subtotal
VI. Diagnostic Testing
Diagnostic Test
Schedule
Purpose
Cost per month
Cost per year
Subtotal
VII. Future Adjunctive Therapies
Therapy
Purpose
Frequency
Cost per month
Cost per year

21. Subtotal
VIII. Medical Equipment
Equipment
Purpose
Purchase/Rental
Cost per month
Cost per year
Subtotal
IX. Transportation
Mode
Purpose
Purchase/PRN
Cost per month
Cost per year

22. Subtotal
X. Home Furnishings and Adaptations
Need
Purpose
Initial cost
Upkeep
Final cost
Subtotal
XI. Potential Complications
Complication
Estimated Cost

23. Subtotal
Financial Summary
Description
Cost per Year
Non-recurring cost
I. Future Medical Care - Routine
II. Future Medical Care - Specialty
III. Treatment Interventions
IV. Medication Needs
V. Supplies
VI. Diagnostic Testing
VII. Future Adjunctive Therapies
VIII. Medical Equipment
IX. Transportation
X. Home Furnishings and Adaptations

24. XI. Potential complications
TOTAL:
V. REFLECTION AND CONCLUSION