The attending doctor is responsible for a patient’s care and determines the patient’s readiness for discharge based on the policies and relevant criteria or indications of referral and discharge established by the hospital policy guiding the referral or discharge of patients .
Referring or discharging a patient to a health care practitioner outside the hospital, another care setting, home, or family is based on the patient’s health status and need for continuing care or services.
Continuity of care requires special preparation and considerations for some patients, such as for discharge planning.
Discharge Planning is a process which is initiated as soon as possible upon inpatient admission, that is during the initial assessment which includes determining the need for patients for whom discharge planning is critical due to age, lack of mobility, continuing medical and nursing needs, or assistance with activities of daily living, among others.
The discharge planning process includes a mechanism to identify those patients for whom discharge planning is critical. A discharge planning worksheet is generated based on a list of criteria and used as an assessment tool by a case manager or an utilisation manager (if there is one at your hospital, or in most instances initiated by a nurse), to identify patients who may require post-hospital services on discharge for inpatients once their acute phase of illness has passed. This worksheet is used to develop the Case Management Note which is a progress note documented by the case manager or an utilisation manager (if there is one at your hospital, or in most instances by a nurse),which outlines a discharge plan that includes case management/social services provided and patient education.
Discharge planning involves discussions on discharge plans with patients and their families on admission and during the hospital stay. A discharge plan is prepared to help determine home needs, assist in planning for needed medical equipment, helps in choosing a facility for care if the patient is unable to return home, and facilitates discharge to home or transfer to another facility.
The Case Management Note is not the same document as the Discharge Note which is the final progress note documented by the attending doctor, which includes details like the patient’s discharge destination (e.g., home), discharge medications, activity level allowed, and follow-up plan (e.g., office appointment).
Health Information Management (HIM) / Medical Records (MR) practitioners do take note that Health Information Management / Medical Records Management services does not include Discharge Planning. However HIM / MR practitioners can expect to find a Case Management Note included in some patients’ medical records.
HIM / MR practitioners who are members of a closed Medical Record Review, need to be aware that the Medical Record Review Tool will assess and determine the degree of compliance with standards and elements of performance relating to discharge planning given to some patients as required by the Joint Commission International (JCI) Standard AOP.1,11 which states that “The initial assessment includes determining the need for discharge planning.”, if you are working at a hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status.
I like to point out that the Medical Record Review Tool has an error that shows the JCI Standard AOP.1.8.1 (Early screening for discharge planning) as found in the JCI Hospital Survey Process Guide, 3rd Edition, Effective January 2008 instead of showing the JCI Standard AOP.1,11 with regards to compliance in discharge planning. You can find my corrected version of this JCI recommended Medical Record Review Tool from this link (the form will open in a new tab of your current window).
References:
- Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
- Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA
