Quality Care
communication
Shared decision-making
TIPS to make decisions
Discharge/TranSfer
Informed consent
End of life
Discharge/Transfer
En Español | Improving care coordination after discharge from the hospital is important for the patient, for the hospital and for the health care system.
Care coordination is essential for a successful recovery, by knowing what to expect, who to call if issues arise or if you have a question, and which community services are available that can assist with the transition process, will improve our recovery.
If you believe you are being discharged too soon, you or your caregiver should inform the medical team and the social worker that you disagree with the discharge plan, you can contact your primary care provider or your insurance company and ask them to intervene. If you are a Medicare patient you can request a fast appeal, this will buy you 24 hours to contest the discharge.
Discharge Instructions Should
Describe what is the healing period is expected to be like, how long will it take to heal, and which symptoms may accompany the process.
List activities or dietary restrictions that aid with recovery.
Describe how to treat any condition such as external bleeding, swelling, etc.
If pain medication is provided, it should be tailored to mild, moderate and severe pain stages, giving the patient the option to start with the mildest medication.
If anesthesia was given, provide warnings and possible side effects and describe what to expect.
Describe care management in stages: the first 24 hours, 3 days, first week, second week, and so on depending on the case.
Provide fact sheets and recent articles about the patient’s condition.
List any complementary modality that may be favorable for the healing process.
Identify signs that constitute an emergency and how to proceed.
Provide a contact number in case of problems or concerns.
If there are changes in the patient’s daily life, it should:
Encourage patients to get involved in community centers that work to improve specific ailments.
Include techniques on how to improve self-care and reduce social barriers.
Include contact information for public agencies, and/or non-profit organizations that provide support.
Discharge Checklist
chart summary
Get copies of your records and review that there are no errors. Records can include the Hospital Discharge Summaries, Specialist Consultation Reports, and Emergency Room Findings. If you had surgery you might need to ask for an Operative Report. Some records come from the nurse, others from the billing office.
medication reconciliation
Thorough review of all medication should be part of discharge planning. Medication should be reconciled to ensure there are no duplications, omissions, and no harmful side effects form the pre-hospitalization medication over the post-discharge list.
Know what each new medication given is for, are they covered by your insurance?
For the new medication: review for interaction, understand instructions, side effects to watch for, and schedule. Know who to call if there are unwanted side-effects to the medications (e.g., primary care vs. surgeon).
discharge instructions FOR
the healing process
Have a number to call in case you have questions or concerns.
What should I expect from the healing period? What symptoms usually accompany the process?
What signs should you watch for that might indicate the healing process is not going well, or having a poor reaction, or developing an infection? Which provider should you call under those circumstances (e.g., surgeon vs. primary care)?
Know who to call if you develop a loss of appetite, weight loss, depression, anxiety or insomnia.
post operative instructions
Are there, clear instruction on how to treat wounds, bleeding, swelling, bed soars?
Do I need to monitor any vital signs such as blood pressure or temperature? Should they be written down? When would they be of concern?
Are special equipments, catheters, feeding tubes needed? Have instructions been given on how to handle them?
daily activities
Are there any restrictions on walking, eating, drinking, bathing, lifting, etc.?
How soon can I drive, exercise, resume sexual activity, return to work?
diet
Do I need to follow a special diet? For how long?
Can I continue taking vitamins and supplements? Are there any I should avoid?
FOLLOW-UP
When will the follow up appointment be, has it been scheduled? Who is responsible for scheduling it?
If test results are not available at time of discharge, know which physician to call in order to follow up with results.
If discharged to a nursing facility for how long am I authorized to stay? Will insurance cover it?
Is telemedicine available?
REHABILITATION
Will there be a visiting nurse? Has the doctor signed the order? For how long can he or she stay?
Do I need physical therapy needed? For how long? When do I start? Has it been scheduled? Is there a phone number to call in case it needs to be rescheduled?
Is medical equipment needed? Has the order been placed? Has it been filed with the insurance? For how long will it be needed?
DISABILITY/WORKERS COMP
If applying for disability or worker’s compensation, has the documentation been submitted? Who can one contact if more information is needed?
referrals
Have referrals been given to transfer facilities?
Have community resources been provided such as meal delivery services, transportation services, supportive organizations, adult day cares, public agencies?
Know the Signs of:
Clots: swelling, redness, or breathing difficulties. Blood clots can occur weeks after leaving the hospital. Ask if they should be walking or taking medication to prevent it.
Wound, blood or urinary tract infection: fever, redness, rashes, swelling around incision, pain, drainage from incision, and painful urination.
Internal bleeding and shock: shortness of breath, pale skin or feeling cold, low urine output, mental confusion or rapid breathing.
Discharge Summaries Include:
Informed consent documents
Surgical Notes
Therapy Notes
Medical Tests and Results
Billing records
List of Prescriptions
Instruction given
Appointment visit notes
Doctors notes
Orders
RESOURCES
Phone: (800)445.8106
They provide resources for caregivers.
Law firm that provides information, advocacy, and assistance regarding Medicare.
Quality Improvement Organizations. Provide assistance on how to file a complaint for a discharge you consider is done too early.
Information About Services
Phone: (800) 677.1116