PATIENT DISCHARGE IN HOSPITAL – 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

COMMON NURSING PROCEDURES IN ICU WARD

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

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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.