Discharge & Follow-Up

A summary of the stay, the final health check for mother and baby, and the going-home plan that follows. Use this document to align everyone — family, pediatrician, and our care team — on next steps.

Discharge Summary

Mother's name:

Baby's name:

Total nights stayed:

Discharge date:

Going-home destination:

Mother — Final Health Check

Temperature:

Blood pressure:

Pulse:

Lochia status:

Incision / perineal status:

Weight at discharge:

Mental wellness:

Lactation status:

Recommendation for the mother going forward:

Baby — Final Health Check

Final weight:

Weight change from birth:

Length:

Head circumference:

Jaundice resolved:

Feeding established:

Sleeping pattern:

Pediatrician handoff date:

Going-Home Care Plan

Feeding plan for the next 4 weeks:

Sleep schedule and routines:

Mother's recovery plan:

24-hour newborn helpline shared:

Lactation consultant scheduled:

Postpartum check-up scheduled:

Mental wellness resources shared:

Family informed of the care plan:

Referrals

Lactation consultant — name:

Lactation consultant — contact:

Pediatrician — name:

Pediatrician — contact:

Postpartum doula — name:

Postpartum doula — contact:

Mental health specialist — name:

Mental health specialist — contact:

Traditional medicine practitioner — name:

Traditional medicine practitioner — contact:

Service Feedback

Food quality (1-5):

Food quality — comments:

Staff care (1-5):

Staff care — comments:

Facilities (1-5):

Facilities — comments:

Overall NPS (0-10):

Renewal & Referrals

Would you stay with us again?

Yes

Maybe

No

Would you refer us to family or friends?

Yes

Maybe

No

Testimonial we may share (optional):

I give permission to use my photo alongside the testimonial

Signatures

Mother:

Center representative:

Date:

Final Acknowledgement

Care plan reviewed and accepted

Thank you for trusting us during these precious first weeks. We wish your family a calm, joyful homecoming — and we are here whenever you need support.

Authorized representative — printed name:

Signed date:

Signer — printed name:

Signed date: