ICU Patient Post-Discharge Follow-up Assessment
Patient Information
Patient Name
Date of Birth
Patient ID
Date of ICU Discharge
Contact & Follow-up
Follow-up Date
Follow-up Time
Method of Follow-up
In-person
Telephone
Video Call
Other
Physical Health Assessment
Current Symptoms
Vital Signs
Mobility Status
Independent
Needs Assistance
Bedbound
Mental Health Assessment
Consciousness & Orientation
Anxiety/Depression
Functional Status
Daily Activities (ADL)
Other Functional Concerns
Medications
Current Medications
Medication Adherence Issues
Care Plan & Referrals
Recommendations
Referrals
Additional Notes