Logo HCS CARDIAC CARE CENTER SOP ID -GNSOP001

Version No: 01

Approved by DISCHARGE PLANNING Date of Approval

DISCHARGE PLANNING
1. Introduction:
Discharge planning begins at the time of admission. The discharge plan shall ensure that every
patient is assessed on admission for discharge needs. A discharge plan is developed for every
patient, documented, and initiated.

Discharge Planning is one such thing which provides information to the in regards to discharge
of the patient.
2. Objective:
This policy applies for all patients admitted as Inpatient to the hospital. Surgical and
Observation patients may require discharge planning.

To standardize the process for discharge planning

3. Workflow:

4. Detailed work instructions:

1. Discharge planning will begin on admission with the initial nursing assessment being
reviewed by the Case Manager to determine post-discharge needs of the patient.

A. Assessments will include:

1. Assessment of the patient ability to perform activities of daily living

(ADLs)

2. Assessment of whether or not the needs of the patient were being met
pre-admission.

3. Assessment of the patient ability to perform self-care.

4. Assessment of the patient’s support person to provide care.

5. Assessment of the possible need for medical equipment.

6. Assessment of need for home environment modifications.

7. Assessment of available community-based services that may be

needed.

8. Assessment of the patient’s insurance coverage (if applicable) and how

that coverage would or would not provide for post-discharge needs.

9. Was the patient’s family or support person included in the discussion

of post-discharge needs?
2. A plan of care will be developed, implemented and documented in the record identify
needs and plans to address those needs.

3. The physician will be consulted as needed to obtain necessary consults or orders to

meet other patient needs.

4. Patient and family education will be provided as needed during the patient’s stay and
will be documented in the record.

5. The discharge plan may change and/or be redefined during the patient’s stay and will
be a multi-discipline, collaborative effort.

6. Discharge planning can include but is not limited to the following:

a. Therapy consults

b. Home oxygen set-up and delivery

c. Post-discharge appointment planning

d. Medication education and assistance with obtaining home medications

e. DME set up and delivery at home i.e. hospital bed, walker, etc.

f. Social assistance

g. Nursing home or personal care home placement

h. Home Health care referral

i. Insurance authorization requests

j. Sending of necessary medical information to the post-discharge provider.