Documenting the discharge process

Whether writing a note, completing a flow sheet, or entering information in an electronic record, a discharge planner is capturing data: facts related to actions, reactions, and decisions. For the purposes of this example, a discharge planner is writing the story about the planning that occurs to prepare for a patient’s transition to the next level of care.

Information entered into the medical record describes the final discharge plan for the patient. Organizations implement documentation policies to guide discharge planners regarding what the medical record must include. This chapter emphasizes which information a medical record must include for discharge planning purposes. It also emphasizes the final discharge plan from regulatory and revenue cycle management perspectives.

The Conditions of Participation (CoPs) describe documentation required during the assessment or evaluation of a patient’s discharge planning needs. The following (c) Standard is taken from the CoPs for discharge planning and should be used as an outline to ensure the minimum evaluation topics are documented in the patient’s medical record:

“(c) Standard: Discharge planning process.

(5) The hospital must consider the following in evaluating a patient’s discharge needs, including but not limited to:

(i) Admitting diagnosis or reason for registration;

(ii) Relevant comorbidities and past medical and surgical history;

(iii) Anticipated ongoing care needs post-discharge;

(iv) Readmission risk;

(v) Relevant psychosocial history;

(vi) Communication needs, including language barriers, diminished eyesight and hearing, and self-reported literacy of the patient, patient’s representative or caregiver/support person(s), as applicable;

(vii) Patient’s access to non-health care services and community-based care providers; and

(viii) Patient’s goals and treatment preferences”

The list above reflects the minimum standards. Discharge planners should use this list as a tool to audit a sample of patient charts to determine whether their hospital meets these minimum requirements. After completing an audit, compare the findings to the facility’s documentation policy to determine whether it addresses all necessary elements. Use this activity as an opportunity to identify potential quality improvement initiatives. You will notice that this list does not include information about the patient’s clinical status. This list is intended to guide a discharge planner or other staff member assessing a patient’s discharge needs and should be part of the documentation policy for the discharge planning department.

Editor’s note: For more information, see Discharge Planning Guide: Tools for Compliance, Fourth Edition, by Jackie Birmingham, RN, BSN, MS, CMAC.