What should be in my loved one's written psychiatric discharge plan?

Ask for a copy before discharge day

Ask the social worker for the written plan before discharge day, so you have time to fix anything missing.

The week after leaving is when many people end up back in the hospital or in crisis. A visit within 7 days is the usual standard, and the hospital should book it before anyone walks out. Telehealth counts.

Medicare's hospital rule says arrangements for care after discharge should be made before your loved one leaves (42 CFR 482.43).

About this checklist

This list is for family members. These are questions to ask, not a legal or clinical form.

1. Who we can talk to

• Did your loved one sign a release naming a family member?
• Name and phone of the hospital contact for the family.
• If your loved one is a minor, or has a personal representative, write that name and phone. Skip this line if it does not apply.
• Date and time of the family meeting.

2. Going home today

• Where will your loved one sleep tonight? Write the address.
• Name and phone of the person expecting them.
• Who is giving your loved one a ride home?
• Who will be with your loved one during the first days?
• If that place is not home, which options did the team contact, such as crisis residential, a group home, or a shelter?
• Is the plan for going home written in the discharge papers?

3. Medications

• List every medication, including the dose.
• What changed, and why?
• What side effects should we watch for?
• Are the prescriptions filled, or is there enough medication until a refill?
• Pharmacy name and phone.
• Is the cost covered?
• Who keeps the medications, and where are they stored?
• Who prescribes after your loved one leaves?

4. First follow-up within 7 days

The week after leaving is when many people end up back in the hospital or in crisis. A visit within 7 days is the usual standard, and the hospital should book it before anyone walks out. Telehealth counts.

• Date, time, and name of the clinician.
• Where is the visit, or is it by telehealth?
• Was the visit booked before leaving?
• Is the visit on a later day, not the day of discharge?
• Were records sent to the next clinician?
• Is there a backup visit within 30 days?
• How will your loved one get there?

5. Ongoing care and daily life

• What care continues? Examples are therapy, psychiatry, peer support, a day program (IOP or PHP), or Assertive Community Treatment (ACT), a team that meets your loved one at home.
• Name and phone of that clinician or team.
• What should we do if the first visit is missed?
• If it applies, what is the plan for work, school, or the daily routine?
• Is a physical health follow-up needed?

6. Coverage and costs

• Has anyone started an SSI or SSDI application? A family member can call Social Security at 1-800-772-1213.
• If coverage needs fixing before discharge, who at the hospital will help file an application?
• Is the follow-up visit in network?

7. Warning signs and who to call

• What are the early warning signs for your loved one?
• Who do we call with questions that are not an emergency? Name and phone.
• For an emergency, call or text 988, call the local crisis team, or call 911. Write the local crisis number.
• Who answers medication questions before the first visit? Name and phone.

8. Safety plan

These steps are recommended by the Joint Commission (2024) and Zero Suicide. Federal hospital rules do not list them.

• Was a written copy of the safety plan given to the family?
• Does a family member know the steps in the safety plan?
• Was a plan for firearms and stored medications discussed?
• Is 988 saved in your phone?
• Is a follow-up call planned?

9. Legal status (if any)

Rules vary by state. These are questions to ask, not legal advice.

• Was the stay voluntary, or did a court order it?
• Are there conditions, or an outpatient treatment order? What do they require?
• Who do we call about that order? Name and phone.

10. Our concerns and what we can take on

• Are family concerns written in the record?
• Is the reason for discharge written in the record?
• If your loved one cannot come home, what other safe place is planned?
• Who do we call to appeal this discharge, and what is the deadline?
• What can the family member take on, and what can the family member not take on?

11. Did we understand it?

• Can a family member say the plan back in their own words?
• Is a written copy of the plan in hand?
• Is an interpreter needed?

12. Reviewed with

• Family member name, role, and date.
• Staff name, role, and date.
• This is not a consent or legal form.
• Was a copy given to the family before leaving?

If something is missing

Point to the blank line and ask the team to fill it in before your loved one leaves. Print the checklist and take it to the family meeting.