Pre-Discharge Assessment

University of Utah- Inpatient

Rehab
Section 1a: Personal Risk Factors YES NO

1. Are you over the age of 75?  

2. Do you have vision problems?  

3. Have you/do you have arthritis, stroke, Parkinson disease, or CHF?  

4. Do you take 4 or more medications?  

5. Do you have balance, dizziness, or walking problems?  

6. Do you have seizures/problems with blood pressure?  

7. Have you had a fall in the last 6 months?  

8. Do you have any open wounds/infections?  

9. Do you need help with transferring or getting around the house?  

10. Do you need help with any activities of daily living?  

Total (for answer ‘no’): _____

11. If you fall, can you get up on your own?  

12. Can you express your needs verbally or through a communication device?  

13. Do you have access to a cell phone or life alert device?  

14. Do you have an emergency plan in case of a fire, flood, etc?  

15. Do you have family members/friends close by who can help if needed?  

Total (for answer ‘yes’): _____

*Questions 9-12 may assess insight- if therapist disagrees with patient’s answer, please note that by
each question. Per disagreement, subtract 1 point.

Section 1b: Environmental Risk Factors YES NO

1. Do you have handrails/ramp/other accessibility options inside/outside your house?  

2. Do you have grab bars (or other modifications) in the bathroom?  

3. Is the lighting inside and outside your home good?  

4. Have you removed all rugs/mats out of hallways/high traffic areas in the  

home?

5. Do you have enough room in smaller parts of your home to use your walker or  

wheelchair? (i.e., clutter free)

Total (for answer ‘yes’): _____

Page total: ____/20

Section 2: Functional kitchen assessment

1. Set up kitchen with the hazards listed below:

 Throw rug/mat rolled up in one corner

 Towel lying on stove
 Medications spilled on countertop and floor
 Bottle of 409 cleaner stored with cooking oils
 Cord plugged into wall and lying across floor in walking area
 Knife upside down in dish drying rack (optional)

2. Instruct patient to ambulate/propel themselves around the kitchen and identify hazards, why it is a
hazard, and how to change them.

Use the following sheet to determine a functional safety score.

KITCHEN SAFETY SCORE SHEET

YES NO

1. Is the patient demonstrating safe functional mobility? (w/ or w/o wheelchair)  

Hazard/rationale Solution

2. Throw rug/mat rolled up in one corner  

3. Towel lying on stove  

4. Medications spilled on countertop/floor  

5. Bottle of 409 cleaner stored with cooking oils  

6. Cord plugged into wall and lying across floor  

7. Knife upside down in dish drying rack  

Total score (including #1): _____/13___

Section 3: Activities for safety awareness/cognition

1. Medication Management

 Instruct patient to organize the listed medications in the provided pill box. Points are given for
correct identification and organization of medication in pillbox.

Use the following sheet to determine a medication management score.

MEDICATION MANAGEMENT SCORE SHEET

Identification Organization

1. Amlodipine (NORVASC)  

2. Apixaban (ELIQUIS)  

3. Atorvastatin (LIPITOR)  

4. Fluoxetine (PROZAC)  

5. Losartan (COZAAR)  

6. Omeprazole (PRILOSEC)  

7. Senna  

8. Sotalol (BETAPACE)  

9. Meclizine (ANTIVERT)  

10. Trazodone (DESYREL)  

Total score (including #1):_____/20___

2. $1,000 winner!

 Hand patient all provided prize sheets. Instruct patient to read over the information and ask
them “What would you do if you received this in the mail?”
o If patient recognizes this is a fake prize and therapist provides 0 assistance
(cueing/physical assistance)- Pt receives a total score of 1 point
o If patient is unable to determine this is a fake prize, or if therapist has to provide any
assistance- Pt receives a total score of 0

Total score: ___/1__

3. Safety Awareness Photographs

 Instruct patient to identify safety hazard and a solution to the problem for the provided
photographs.

Use the following sheet to determine a safety awareness score.

SAFETY AWARENESS PHOTOS SCORE SHEET

Hazard Solution

1. Towel on stove  

2. Aluminum foil in microwave  

3. Hairdryer in sink  

4. Numerous cords  

5. People walking on ice  

6. Changing lightbulb  

7. Rolled up throw rug  

8. Cutting hotdog  

9. Scissors in toaster  

10. Child reaching under sink  

11. Water on bathroom floor  

12. Using oven without oven mitts  

Total score (including #1): _____/24___

Overall Assessment Score (Add together Section 1, 2 and 3): _____/78__

 Tips/Compensatory Strategies for Improving Medication Management

1. Use an automatic or locked pill box dispenser

2. Designate a family member/caregiver to organize your medications
3. Double check your pills after a family member/caregiver organizes them
4. Manage pills with easy instructions (while a family member/caregiver manages medications that
are more complicated)
5. Provide patient with cues/guidance
6. Grade medication management activity up or down depending on patient’s needs and ability

Tips/Compensatory Strategies for Cognition and Safety

1. Allow family member/caregiver to look through all mail/documents with you

2. Read small print on suspicious documents (may need to use magnifying glass)
3. Do not give out personal information to unfamiliar parties (in person, online or over the phone)
4. Double check any coupons/awards received in mail/over the telephone with family members or
caregiver
5. Be aware of your surroundings- look for obstacles on floor (rugs, cords), sharp objects on
counter/sink
6. Store food products away from cleaning products
7. Set timers to check on oven/turn off oven
8. Avoid placing towels by oven
9. Allow family members to help during complex meal prep and cooking tasks
10. Increase supervision level (supervision provided by family members or hired help)