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  1. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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