Discharge Planning Notes

Discharge Planning

  • Process of transitioning a patient from one level of care to the next.
  • Individualized instructions for continued care outside the healthcare facility or independent living at home.
  • Purpose: To improve the client’s quality of life by ensuring continuity of care.

Key Elements of Ideal Discharge Planning

  • Include the patient and family as full partners.
  • Discuss five key areas:
    • What life at home will be like
    • Review medications
    • Highlight warning signs and problems
    • Explain test results
    • Schedule follow-up appointments
  • Educate the patient and family in plain language.
  • Assess understanding using teach-back.
  • Listen to patient's and family's goals, preferences, observations, and concerns.

Specific Components of a Discharge Plan

  • Equipment needed at home.
  • Dietary needs or special diet.
  • Medications: List, purpose, dosage, administration, and side effects.
  • Resources: Contact numbers and addresses.
  • Emergency response: Danger signs.
  • Home care activities: What to do or avoid.
  • Summary: Discuss condition, process, and follow-up.

Patient Outcomes Criteria - Nursing Order

  • Assessment:
    • Patient’s readiness, home situation, physical capabilities, and financial resources.
    • Understanding of instructions.
  • Planning:
    • Health teachings, restrictions.
    • Patient will perform activities of daily living.
    • Monitor and document progress.
    • Follow-up check-up.
  • Implementing:
    • Medication adherence.
    • Range of motion exercises.
    • Ambulation.
    • Maintaining cleanliness.
    • Discuss instructions and health teachings.
    • Locate nearest health facility.
    • Identify support persons.
    • Address concerns.
    • Inform about recurring signs and symptoms.
    • Emphasize vital signs monitoring.
    • Instruct medication regimen (e.g., Amlodipine besylate 10mg/tab OD po).
    • Instruct on ROM exercises and ambulation.
    • Instruct on maintaining a clean environment.
  • Implementing Acronym: METHOD

Patient Outcomes Criteria - Nursing Order (Cont.)

  • Implementing (Cont.)
    • Consult physical therapist.
    • Exhibit health care activities (bathing, oral care, handwashing).
    • Observe for recurring signs and symptoms.
    • Return for follow-up.
    • Follow a low salt, low fat diet.
    • Spiritual activities.
  • Evaluating:
    • Patient verbalizes understanding.
  • Acronyms:
    • M (Medication), O (Outpatient/Objective), E (Exercise/Environment), D (Diet), T (Treatment), H (Hygiene), S (Spiritual)
  • Encourage physical counseling/therapy.
  • Advise on hygienic measures.
  • Advise on signs/symptoms and consultation.
  • Advise on prescribed diet.
  • Encourage faith and participation.
  • Evaluate understanding.