Patient Discharge – Nursing Procedure

UPDATED 2024

DISCHARGE PROCEDURE

The discharge procedure in a healthcare setting is a critical aspect of patient care, ensuring a smooth transition from the hospital to home or another care setting.

Effective
discharge requires careful planning and continuing assessment of the patient’s
needs during his hospitalization. Ideally, discharge planning begins shortly
after admission.

Discharge Process

Discharge is the termination of care from a health care agency. Planning for discharge actually begins on admission, when information about the patient is collected and documented. The key to successful discharge planning is an exchange of information among the patient, the caregivers, and those responsible for care while the patient is in the acute care setting and after the patient returns home. This coordination of care is usually the nurse’s responsibility

Discharge Planning Aims to:

Discharge is
preparation of patient to leave hospital and to return to own environment.
Patient is prepared for discharge when he is admitted in the hospital. He
should be prepared physically and mentally to leave the hospital or ward

Discharge
planning is the plan evolved before a patient is transferred from one
environment to another. This process involves the patient, family, friends, and
the hospital and community healthcare teams

Discharge
planning is an integral part of the continuity of nursing care for patients
throughout their hospital stay.

Purpose

• To ensure continuity of care to
  patient after discharge
• To assist patient to complete
  hospital formalities before returning home
• To assist patient to return to a
  state of optimal independent living
• To assist the patient in discharge
  process
• To acknowledge patients right in
  deciding to leave hospital

Reasons for Discharge

• Cured
• Transfer to other hospital
• Discharged at request
• Discharged against medical advice
• Death

Equipment

Wheelchair,
unless the patient leaves by ambulance, patient’s chart, patient instruction
sheet, discharge summary sheet, plastic bag or patient’s suitcase for personal
belongings

General Instruction

Prepare
patient and family during hospitalization with adequate information in relation
to probable date of discharge, approximate in patient bill and relevant home
care

Departments to be informed

• Drug return to pharmacy department
• Diet cancellation
• Oxygen/ventilator charges summary
• Accounts department
• Billing section

Preliminary Assessment

• Check doctor’s written orders for
  discharge
• Inform patient and relatives about
  discharge
• Document relevant discharge
  information
• Make sure all the fees are included
  such as special investigations, special matters or devices, doctors or
  surgeon’s fees and narcotic drug used (if any)
• Obtain discharge prescription after
  retaining the medicines to be continued for that day and after discharge. Send
  all other continued for that day and after discharge. Send all other medicines
  for refunding (include ward replacement)
• Send chart to billing section with
  relevant information
• One bill is ready and chart is
  received back in ward, ensure that bill is settled. Check the cashier’s
  signature in the discharge bill
• Help the patient to obtain discharge
  summary, medical certificate and drugs
• Ensure that patient is instructed
  regarding medication follow up, outpatient visit, etc
• Accompany the patient up to transport
  near exit gate

Procedure

• Before the day of discharge, inform
  the patient’s family of the time and date of discharge
• Obtain a written discharge order from
  the physician. If the patient discharges himself against medical advice, obtain
  the appropriate form
• If the patient requires home medical
  care, confirm arrangements with the appropriate facility department or
  community agency
• On the day of discharge, review the
  patient’s discharge care plan (initiated on admission and modified during his
  hospitalization) with the patient and his family. List prescribed drugs on the
  patient instruction sheet along with the dosage, prescribed time schedule, and adverse
  reactions that he should report to the physician. Ensure that the drug schedule
  is consistent with the patient’s lifestyle to prevent improper administration
  and to promote patient compliance
• Review procedures the patient or his
  family will perform at home. If necessary, demonstrate these procedures,
  provide written instructions, and check performance with a return demonstration
• List dietary and activity instructions,
  if applicable, on the patient instruction sheet and review the reasons for them
• Check with the physician about the
  patient’s next office appointment; if the physician hasn’t yet done so, inform
  the patient of the date, time and location
• Retrieve the patient’s valuables from
  the facility’s safe and review each item with him. Then obtain the patient’s
  signature to verify receipt of his valuables
• Obtain from the pharmacy any drugs
  the patient brought with him
• If appropriate, take and record the
  patient’s vital signs on the discharge summary form. Notify the physician if
  any signs are abnormal such as an elevated temperature
• Help the patient get dressed if
  necessary
• Collect the patient’s personal
  belongings from his room
• After checking the room for misplaced
  belongings, help the patient into the wheelchair, and escort him to the exit;
  if the patient is leaving by ambulance, help him onto the litter
• After the patient has left the area,
  strip the bed linens and notify the housekeeping staff that the room is ready
  for terminal cleaning

Special Considerations

• Whenever possible, involve the
  patient’s family in discharge planning so they can better understand and
  perform patient care procedures
• Before the patient is discharged,
  perform a physical assessment. If you detect abnormal signs or the patient develops
  new symptoms, notify the physician and delay discharge until he has seen the
  patient

Documentation

• Record the time and date of recharge
• The patient’s physical condition
• Special dietary or activity
  instructions
• The type and frequency of home care
  procedures
• The patient’s drug regimen
• The dates of follow-up appointments
• The mode of departure and name of the
  patient’s escort
• A summary of the patient’s hospitalization,
  if necessary

After Discharge

• Record time, date and condition of
  the patient at departure
• Send chart to medical record
  department and inform to the concern departments
• After the patient has gone, the bed
  should be washed, blankets kept in sunlight, Mackintosh washed and dried
• The room cleaned, all utensils
  cleaned and kept ready for next use
• In case of infected cases, utensils
  should be disinfected and then cleaned. The linen should be disinfected and
  then send to laundry
• When discharging the medicolegal
  cases, the patient dead body should be handed over to the police, before that
  concerning police station should be informed about the patient’s
  discharge/death
• Patient or dead body is handed over
  to the police and asks the police to sign with date and time

Discharge Teaching Goals

• Understand his illness
• Complies with his drug therapy
• Carefully follows his diet
• Manages his activity level
• Understands his treatments
• Recognizes his need for rest
• Knows about possible complications
• Knows when to seek follow-up care

PATIENT ABSCONDED FROM HOSPITAL

• Patient went out of the hospital
  without Doctor’s or other staff’s knowledge
• Hospital does not know that the patient
  left and they do not know when the patient left
• They found out during next rounds
• Patients may not have discussed with
  the doctor/hospital about going out
• It is wrong to write, for example,
  that the patient absconded at 7 PM. If the doctor (either directly or through
  other paramedical staff) knows the time patient went out, it is not absconded;
  it is Left against Medical Advice

Left against Medical Advice (LAMA)

• Doctor asked the patient to
  stay/continue treatment
• Patient/patient’s relatives did not
  inform their plan of leaving the hospital, but they left suddenly
• But the hospital was aware of them
  going out and the time patient left
• Doctor had said that taking the
  patient out may endanger life
• Patient/patient’s relatives did not
  sign anything
• Hospital may not give any discharge
  summary
• In fact, patient may not have
  discussed with the doctor/hospital about going out
• Since the doctor (either directly or
  through other paramedical staff) knows the time the patient is going out, it
  should be recorded as “Patient left Against Medical Advice”

DAMA: DISCHARGED AGAINST MEDICAL ADVICE

• Doctor has clearly explained that
  taking the patient out may endanger life, but still patient/patient’s relatives
  want to take the patient to some other hospital
• They sign a declaration saying that
  the risks were informed to them – by taking the patient out of hospital, they
  are immediately endangering the life
• Hospital gives a discharge summary

Occasionally,
the patient or his family may demand discharge against medical device (AMA). If
this occurs, notify the physician immediately. If the physician fails to
convince the patient to remain in the facility, he will ask the patient to sign
an AMA form releasing the facility from legal responsibility for any medical
problems the patient may experience after discharge. If the physician is not
available, discuss the discharge form with the patient and obtain his
signature. If the patient refuses to sign the AMA form, do not detain him. This
violates his legal rights. After the patient leaves, document the incident
thoroughly in your notes and notify the physician

As a guide
to the AMA process, consider the following list of Do’s and Don’ts:

• Don’t ignore the patient who wants to
  leave AMA. If at all possible, stop what you are doing and prepare to address
  the issue
• Do determine the decision-making
  capacity of the patient. Do they comprehend the information and consequences
  and understand the risks and benefits of the options, and can they communicable
  these back to you?
• Don’t blame or berate the patient or
  anyone else for his desire to have
• Do apologize of the patient has been
  waiting or if there have been delays in the patient care process. Apologies are
  free. Lawsuits cost millions
• Don’t just ask the nurse to have the
  patient sign a generic AMA form and leave. This course of action provides
  little protection for the practitioner
• Do enlist the patient’s family and
  friends in your attempt to convince the patient to stay
• Don’t express your frustration and
  anger to the patient. Instead, earnestly convince him that your overriding
  interest is his well-being. Make sure he knows that you are on his side against
  a potential threat to his health
• Do document the patient’s “informed
  refusal” of crucial diagnostic testing (e.g. blood work or X-rays), procedures
  (e.g. LP to rule out meningitis or subarachnoid hemorrhage), or treatments
  (e.g. medications or transfusions) in the small detail as you would an AMA
• Don’t refuse to provide treatment;
  this could be considered abandoning the patient. Provide whatever treatment,
  prescriptions, follow-up appointments, and specific discharge instructions the
  patient will accept
• Do document the details of the AMA
  patient encounter in the patient’s chart. Include documentation of the
  patient’s decision-making capacity, the specific benefits of your proposed
  treatment and risk of leaving AMA, what you did to get the patient to stay, and
  your compassionate interest in having the patient return for any reason. Have
  the patient sign an AMA form that addresses these details, witnessed by a
  family member and/or staff member
• Don’t worry about whether or not the
  patient’s insurance will deny payment if he signs out AMA. His insurance is not
  your problems, but a malpractice suit will definitely by your problem.

LAMA: LEAVE AGAINST MEDICE ADVICE

LAMA has
been defined in the broadest terms as any patient who insists upon leaving
against the expressed advice of the treating team. Escape (absence without
leave, absconding, or elopement), whereby the patient leaves the hospital
without notification by escaping from an involuntary unit or walking out of a
voluntary unit, also has been considered by some clinicians and researchers to
be a form of discharge against medical device. Others do not regard escape as a
form of discharge against medical advice because the essential element of
physician’s expressed advice against leaving is lacking in this situation

MEDICOLEGAL CASES

A medicolegal
case is one where besides the medical treatment; investigations by law
enforcing agencies are essential to fix the responsibility regarding the
present state/condition of the patient. The case, therefore, has both medical
and legal implications

Registering
MLC is a MUST: attending casualty medical officer (CMO) has the authority to
decide whether the case is to be registered as medicolegal or not. There is no
scope for acceding to request/pressure from the relatives, patient himself or
his colleagues regarding the registration of MLC. Even if the accident (e.g.
trauma) has happened several days ago, if the complaints merit an MLC, then MLC
should be registered.

Medicolegal
cases: the following cases should be considered as medicolegal and as such the
medical officer is “duty-bound” to intimate to the police regarding such cases:

• All cases of injuries and burns – the
  circumstance of which suggest commission of an offence by somebody
  (irrespective of suspicion of foul play)
• All vehicular, factory or other
  unnatural accident cases specially when there is a likelihood of patient’s
  death or grievous hurt
• Cases of suspected or evident sexual
  assault
• Cases of suspected or evident
  criminal abortion
• Cases of unconsciousness where its cause
  is not natural or not clear
• All cases of suspected or evident
  poisoning or intoxication
• Cases referred from court or
  otherwise for age estimation
• Cases brought dead with improper
  history creating suspicion of an offence
• Cases of suspected self-infliction of
  injuries or attempted suicide
• Any other case not falling under the
  above categories but has legal implications

Admissions and Discharge

• Whenever a medicolegal case is
  admitted or discharged, the same should be intimated to the nearest police
  station at the earliest. It is always better to inform the police through the
  casualty of the hospital where the medicolegal register is usually maintained
  and necessary entries can be made in it
• While discharging or referring the
  patient, care should be taken to see that he receives the Discharge
  Card/Referral Letter, complete with the summary of admission, the treatment
  given in the hospital and the instructions to the patient to be followed after
  discharge
• Failure to do so renders the doctor
  liable for “negligence” and “deficiency of service”
• If the patient is not serious and can
  take care of himself, he may be discharged on his own request, after taking in
  writing from him that he has been explained the possible outcome of such a
  discharge and that he is going on his own against medical advice
• Police have to be informed before the
  said patient leaves the hospital. Sometimes the patient, registered as a
  medicolegal case, may abscond from the hospital. Police have to be immediately
  informed, the moment such an instance comes to the notice of the
  doctor/hospital staff

Death of a
person admitted as a medicolegal case: the following are the do’s and don’ts in
case a person admitted as a medicolegal case expires.

• Inform the police immediately
• Send the body to the hospital
  mortuary for preservation, till the legal formalities are completed and the
  police releases the body to the lawful heirs
• Request a medicolegal postmortem
  examination
• Do not issue a death certificate –
  even if the patient was admitted
• The dead body should never be
  released to the relatives; it should only be handed over to the police

The medicolegal implications of LAMA need to be given serious consideration as the caregiver might not be protected from malpractice charges. There is little evidence that LAMA provides any malpractice protection. Many hospitals have a release form for patients to read and sign prior to leaving hospital against medical advice, relieving the hospital and medical staff of any responsibility related to the patient’s decision or its consequences. Hospital authorities should recognize that forms signed by a patient who is leaving against medical advice designed to protect the hospital in the event of an untoward consequence might have no legal protective value. The danger in such forms is that a physician may be tempted to rely on them instead of good clinical judgment and adherence to the recommended guidelines. The legal standard for protection from lawsuits continues to be good clinical practice with thorough documentation. Use of discharge against medical advice is not a safe road to legal immunity.

PATIENT ADMISSION – NURSING PROCEDURE

PATIENT TRANSFER – NURSING PROCEDURE

NURSING PROCEDURES LIST CLICK HERE

NURSING IMPORTANT QUESTIONS – CLICK HERE

NURSE FUNDAMENTAL PROCEDURES

MEDICAL SURGICAL NURSING

OVERVIEW OF PATIENT DISCHARGE

Here is a general outline of the discharge procedure:

1. Discharge Planning:

• Discharge planning begins early in the patient’s hospital stay. The healthcare team assesses the patient’s needs, coordinates care, and plans for post-discharge support.

2. Medical Clearance:

• Ensure that the patient has received medical clearance and is deemed stable for discharge by the attending physician.

3. Medication Reconciliation:

• Review the patient’s medications, providing instructions for any changes or new prescriptions. Ensure the patient understands the medication regimen.

4. Patient Education:

• Provide thorough education on post-discharge care, including:
  • Medication instructions (dosage, frequency, potential side effects).
  • Wound care (if applicable).
  • Dietary restrictions or recommendations.
  • Activity restrictions or modifications.
  • Signs and symptoms to monitor and report.
  • Follow-up appointments and tests.

5. Rehabilitation and Therapy Services:

• If applicable, arrange for any necessary rehabilitation or therapy services post-discharge. Provide instructions and contact information.

6. Equipment and Home Care Services:

• Coordinate the delivery of any necessary medical equipment, supplies, or home care services required for the patient’s recovery at home.

7. Follow-Up Appointments:

• Schedule follow-up appointments with appropriate healthcare providers. Provide the patient with details, including the date, time, and location.

8. Final Medical Assessments:

• Conduct final medical assessments, such as a final physical examination, and ensure that any outstanding tests or procedures are completed.

9. Completion of Discharge Papers:

• Prepare and complete all necessary discharge paperwork, including the discharge summary, instructions, and any required documentation.

10. Financial Arrangements: – Provide information on any outstanding bills, co-payments, or financial matters related to the hospital stay. Offer assistance in understanding the billing process.

11. Transportation Arrangements: – Arrange for transportation if needed, especially if the patient is unable to drive or requires special transportation services.

12. Patient and Family Involvement: – Involve the patient and their family or caregivers in the discharge process. Ensure they understand the care plan and have the necessary resources for ongoing care.

13. Personal Belongings: – Assist the patient in gathering their personal belongings, and ensure that any valuables kept by the hospital are returned.

14. Handover to Home Healthcare Providers: – If home healthcare services are involved, provide necessary information to the home healthcare team, including the patient’s condition, care plan, and ongoing needs.

15. Ensure Comfort and Confidence: – Address any concerns or questions the patient may have and ensure they feel comfortable and confident in managing their care at home.

16. Departure: – Escort the patient and their belongings to the hospital exit, and ensure a smooth transition to the next phase of care.