Gautham Hospital — Post-Discharge Readiness Check

Inpatient Assessment Form

IP Coordinator Entry

1. Patient Name

2. Age

Gender

3. Room Category

General

Semi-private

Private

Deluxe

4. Consulting Doctor & Department

5. Reason for this Admission

6. Admitted Before for Same / Related Problem

Yes, within 6 months

Yes, earlier

7. Ongoing Conditions (Select all that apply)

Diabetes

Heart

Kidney

Neuro–stroke

Memory or confusion

Other

None

8. Mobility

Independent

Needs some help

Needs full help

9. Falls or Noticeable Decline in Last 6 Months

Yes

Not sure

10. Doctor’s Post-Discharge Instructions (Select all that apply)

Physio

Daily dressing–injections

New medicines

Review visit

Diet changes

None yet

11. Who will be at Home with Patient During the Day after Discharge

Spouse only

Adult child at home

Paid caretaker–nurse

Nobody for parts of the day

12. Children or Close Family Outside India

Yes: Gulf

Yes: US–UK–Europe

Yes: other

13. Main Decision-Maker

Patient

Spouse

Child in India

Child abroad

Joint

14. Does the family expect difficulty managing medicines, follow-ups, diet, mobility or monitoring at home?

Yes

Somewhat

15. Would the Family Like Information About Structured Recovery Support at Home?

Yes

Maybe

✓

Recorded

The care team will review before discharge.

💾 Saved automatically to this device

Inpatient Assessment Form

Review Patient Assessment

Recorded