Q&A: Documenting discharge plans on rounds

Q. How can case managers ensure they are effectively capturing discharge details during rounds?

A. Because of the wide variation in models of rounds, each organization must establish a method of capturing pertinent discharge planning information gathered during rounds. Valuable information may be lost if the rounding team uses a single worksheet for notes, and no one transfers it to the patient’s medical record. For example, a hospital may use a bedside rounds model. While in the room with the patient and family, the team may agree that the patient will be ready for discharge to a SNF for rehabilitation the next day. The discussion with the patient and family includes asking about goals and preferences. Only documenting that a SNF referral will be made will lose the value of capturing the requirement of working with patients’ goals and preferences.

The responsibility for documenting the patient’s assessment and planning, interaction, and decisions should not only be that of the discharge planner. Staff nurses, unit nurses, social workers, or therapists who are working with that patient are the most logical clinicians to document what was discussed in rounds. A way to facilitate this would be to assign a specific rounding team member to document the rounding discussions before the team moves to the next patient. The physician or physician advisor attending rounds should be exempt from documenting findings at rounds since the patient may have another physician, and the physician on rounds would have no reason to access the patient’s chart.

For more information, see Discharge Planning Guide: Tools for Compliance, Fourth Edition.

Need expert advice? Email your questions for consideration in the Revenue Cycle Daily Advisor. Note: We do not guarantee that all questions will be answered.