(1) The client's strengths, needs, abilities, and preferences (SNAP) at the point prior to discharge are documented.
( )
( )
(2) The gains from goals achieved are documented.
( )
( )
(3) The likely postdischarge needs and issues are identified and conveyed to client and caregiver.
( )
( )
(4) Referral to other agencies for post-discharge needs is made, where necessary.
( )
( )
(5) Caregivers are briefed on client needs, and informed with other resources available, including caregiver support groups, respite services, and other community resources.
( )
( )
(6) Contact details of a staff from the discharging organization have been given to client and caregiver.
( )
( )
(7) Assigned staff and social worker had arranged to follow up with the client and caregiver, within a specified time-frame.
( )
( )
(8) Information resources, such as pamphlets of community-based services, health-related information (disease prevention, nutrition or diet, coping skills for caregivers, etc.) had been given to client and caregiver.
