1. Discharges
 Discharge planning begins at admission with the initial interview
and nursing assessment and continues as an interdisciplinary
process throughout the patient’s stay
 The discharge planner is completed as part of the initial
interview on admission which includes assessment of the
patient’s educational, supportive, and home needs
 Admissions are screened daily for established “high risk” criteria
and nursing service makes referrals to the appropriate
departments such as dietary, social, rehabilitative, or home
health services

2. Discharges (continued)
 Social Services is consulted to help facilitate referrals and
set up services that the patient may need at discharge
 This can be done without a physician order
 Discharge planning is coordinated via conferences involving
patient, family, physician, nursing, case management/social
services, and ancillary services as well as outside agencies,
treatment facilities, and/or long term care facilities
according to each individual’s need
 Case Managers collaborate with multidisciplinary teams
daily on each unit and bring findings to the Discharge
Planning Committee
 The committee is composed of respiratory, dietary, physical
therapy, home health, nursing, and case management

3. Discharges (continued)
 Discharge plans are updated and revised on an ongoing basis
 An individualized plan of care is documented in CPSI via the
problem list on admission
 Goals are specific to the patient and are addressed daily by
documenting interventions and evaluations
 Associating nursing orders with the problem list helps to facilitate
this documentation
 Goals are resolved as they are met during the hospitalization
 All goals are addressed at discharge
 At discharge each patient has a completed discharge plan
addressing all areas of post-hospital care and follow-up necessary
to maintain or improve patient’s health

4. Discharges (continued)
 It is the responsibility of the nurse discharging the patient to
evaluate the discharge plan and ensure that sufficient
discharge planning has been completed
 The Discharge Instructions & Medications will be used at
discharge, this affects reimbursement
 All significant wounds are photographically documented on
discharge
 All patients (especially smokers) should be educated on the
dangers of smoking at discharge.
 Medication education should be given to all patients for any
new medications to be started at discharge

5. Discharges (continued)
If the patient has Congestive Heart Failure, it is important to
document that the patient was instructed on the following six
topics:
• Monitoring weight
• Proper diet
• Proper activity level
• What to do if symptoms get worse
• Smoking cessation
• Follow-up with MD
This information is included on the CHF Discharge instructions that
may be printed from CPSI
Click the box on the Discharge Instructions eform to add CHF
information

6. Discharges (continued)
 Whether a patient is on Coumadin at home or started on
Coumadin during hospitalization, Coumadin education is
given to all patients on Coumadin
 This can be done prior to discharge
 Education is provided by Nursing associates using the
“Important Information about Coumadin (warfarin)” envelope
located on each unit containing
• Coumadin Pamphlet
• Coumadin and You DVD
• Coumadin Diary “My Guide to Dosing”
• Coumadin Dosing Card
Also by providing the Coumadin education sheet in CPSI

7. Discharges (continued)
 The discharge planning decision-making process will include
the patient, family, and/or significant other
 Documentation of acceptance of the discharge plan by the
patient, family, or significant other will be clearly documented
in the interdisciplinary progress notes
 WCMC will provide all patients with a list of ancillary providers
for post-hospital care needs (Home Health, DME, Hospice, Out
patient Rehab, SNF, etc.)
 The patient choices will be validated in writing and a copy of
the selection will be filed in the permanent record
 If behavioral health counseling is identified as a need, a referral
for Social Services will be initiated and documented in the
physician orders as a “Social Services Consult”

8. Discharges (continued)
 Upon discharge, the orders written by the doctor are
transcribed into the Discharge Instructions & Medications
eform
 Information regarding post-hospital care
(medications, physician follow-up, outpatient
services, activity level, diet, etc.) is also on the eform
 The patient’s signature on the Discharge Instructions &
Medications eform is evidence of this instruction and is part of
the permanent medical record
 The Discharge Instructions and medication list are faxed to
the patient’s primary care provider and sent home with the
patient

9. Discharges (continued)
 All patients should have a scheduled follow-up appointment post
discharge
 Extra care should be taken to assure Core Measure patients have
an appointment within 5-7 days post discharge
 During office hours the nursing staff will contact a
physician, either the PCP or a consulting physician’s office to
arrange the appointment
 During off hours discharge instructions will include the follow-up
date and instructions for the patient to call the office for a specific
time. The telephone number will be clearly specified for the
patient
 Documentation of appointment; date, time, and person notified
of appointment will be placed in the patient’s chart along with
staff member’s signature

10. Discharges (continued)
 If the patient needs additional resources following discharge
he/she is provided a list of community resources that gives
available agencies located close to the patient’s home for
the patient to choose from
 The patient signs the Community Resource Guide as
documentation that the patient was given a choice in
services
 The Community Resource Guide is located on the intranet
under the department Case Management
 The patient should be Discharged from CPSI in a timely
manner listing the exact time the patient leaves

11. Discharges (continued)
“AMA” – Against Medical Advice
 In the event that a patient expresses the
desire to leave WCMC against the advice of
the primary physician, the attending
physician is notified by the nurse
 The patient or responsible party signs the
AMA form, thus accepting responsibility for
their decisions and it becomes part of the
medical record

12. Discharges (continued)
Transfers Outside WCMC (External)
 Upon receipt of transfer orders, the transfer form is
completed by nursing staff
 When transferring a patient to another acute care facility, a
Consent to Transfer form is completed, although it is not
required for nursing home transfer
 Transportation is arranged at the physician’s discretion
 Copies of the pertinent medical records accompany the
patient at transfer
 Nurse to nurse report occurs by phone prior to the patient’s
departure

13. Discharges (continued)
Transfers Inside WCMC (Internal)
 When orders to transfer a patient are received from the
physician, the primary nurse notifies the nursing supervisor
for bed assignment
 Once bed assignment is established, the primary nurse calls
report to the receiving nurse
 Safety of the patient is kept at the highest priority by
ensuring the appropriate staff, equipment, and medications
accompany the patient
 CCU is notified of room number/unit changes in patient’s
wearing telemetry