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Discharges
Discharges
Discharges
Discharges
Discharges
Discharges
Discharges
Discharges
Discharges
Discharges
Discharges
Discharges
Discharges
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Discharges

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  • 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 todocument that the patient was instructed on the following sixtopics:• Monitoring weight• Proper diet• Proper activity level• What to do if symptoms get worse• Smoking cessation• Follow-up with MDThis information is included on the CHF Discharge instructions thatmay be printed from CPSIClick the box on the Discharge Instructions eform to add CHFinformation
  • 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 CardAlso 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

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