Gautham Hospital
Post-Discharge Readiness Check
Clinical Care Coordination
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The information below is collected by Gautham Hospital and shared with its service providers to facilitate the patient’s treatment, recovery support and follow-up care after discharge.
Inpatient Assessment Form
IP Coordinator Entry
1.
Patient Name
2.
Age
3.
Room Category
General
Semi-private
Private
Deluxe
4.
Consulting Doctor & Department
5.
Reason for this Admission
6.
Admitted Before for Same / Related Problem
No
Yes, within 6 months
Yes, earlier
7.
Ongoing Conditions (Select all that apply)
Diabetes
BP
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
No
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
No
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
No
15.
Would the Family Like Information About Structured Recovery Support at Home?
Yes
Maybe
No
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The care team will review before discharge.
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