Discharge Assessment & Stay Review

As your stay comes to a close, this review captures how you and your baby are doing, what you learned, and how the stay met your needs. You are the best source of this information, so please answer in your own words — your care team will read it before you check out and use it to plan your follow-up.

Section 1 — Stay Details

Mother's name:

Baby's name:

Room number:

Check-out date:

Section 2 — Your Recovery

How is your physical recovery going?

Recovering well — no concerns

Recovering, with some lingering discomfort

Still having difficulty — would like follow-up

How are you feeling emotionally?

Generally positive and supported

Up and down — some hard days

Struggling — I would welcome extra support

Anything about your recovery you would like the team to know:

Section 3 — Feeding & Baby

How is feeding going at this point?

Confident and comfortable

Going well, still building confidence

Finding it hard — would like more lactation help

Any concerns about your baby you would like reviewed before discharge:

Section 4 — Education Received

Please confirm the topics you feel confident about after your stay (tick all that apply):

Feeding and latching

Bathing and cord care

Safe sleep practices

Recognising warning signs in mother and baby

Self-care and rest at home

Any topic you would still like to be walked through before you leave?

Section 5 — Your Satisfaction

Please rate each area from 1 (poor) to 5 (excellent):

What did you appreciate most about your stay?

What could we improve for the next family?

Section 6 — Follow-Up & Home Plan

Which follow-up support would you like after discharge? (tick all that apply)

A follow-up phone call from the care team

Continued lactation support

Referral for emotional / mental health support

Information on newborn check-up scheduling

Best phone number for follow-up:

Preferred follow-up date:

Anything else you would like the team to arrange or know before you go home:

Section 7 — Confirmation & Signature

The information in this review reflects my own experience and is accurate to the best of my knowledge.

I have received the discharge education and instructions I need for home care.

I consent to being contacted for the follow-up support I selected above.

Client — printed name:

Date:

Optional — upload any document you would like to share with the team (e.g. a discharge photo or note):

Thank you for trusting us with the start of your family life together. We will follow up as you requested — and our door is always open when you need us.