SALALE UNIVERSITY COMPREHENSIVE SPECIALIZED HOSPITAL
Policy, procedures and process for discharging planning for selected NCD
Compiled By: Dr Shallo A. Signature:
Reviewed By: Dr Diriba Shiferaw (Chief Clinical Director) Signature:
Approved By: Dr Mieso Bayu (Chief Excutive Director) Signature:
Effective Date: September 5, 2025 Version No. 1.0
Document No: 1 Copy No. _1.
Salale University Comprehensive Document No: SLUCSH/PSI/MSOP-001
Specialized Hospital Version No: 1.0
Policy, Process and Procedures for Page: 2
discharge planning for selected NCDs Effective Date: September 5, 2025 GC
1. Purpose
Ensure safe, timely, and coordinated transition of patients from hospital to home or other care
settings, reduce avoidable readmissions, ensure continuity of care and patient/family
understanding of care plan.
2. Scope
Applies to all inpatients and those held for observation in the hospital. Discharge planning begins
at admission and continues until after documented follow-up.
3. Key Principles
• Start discharge planning at admission and update throughout stay.
• Multidisciplinary: physician, nurse, pharmacist, social worker, physiotherapist (for selected
cases)
• Patient and family engaged in decisions and education; use teach back to confirm
understanding.
• Document everything in the medical record and a standardized discharge summary form.
4. Roles & Responsibilities
• Physician: Determines clinical readiness, completes discharge orders, prescribes follow-up
and investigations, signs discharge summary.
• Nurse: Initiates discharge checklist, provides patient education, coordinates logistics, ensures
home support arranged.
• Pharmacist: Performs medication reconciliation, counsels patient, provides medicines or
prescription, documents counseling.
• Physiotherapist (for selected cases): Provides therapy instructions and equipment
prescriptions and arranges physiotherapy follow up
• Liaison: Oversees process, tracks pending discharges, ensures documentation and gives
blocked follow-up appointments as per our hospital appointment system.
• Patient & caregiver: Participate in discharge planning, raise questions, confirm
understanding, adhere to prescribed medications and return for follow up.
5. Discharge Planning Process & Timeline
1. Initiate discharge plan sheet in chart at admission
2. Senior physician audits the chart, cosigns the admission (if admitted by GP or resident) and
assess the patient within 24–48 hours as per our hospital protocol. He/she should also update
expected discharge date; track outstanding lab investigations, meds and consultations.
3. Patients should receive standard of care under senior physicians who makes at least two MDT
rounds per day. Nurses should participate in patient education about their conditions in
language they understood and ensure that the patient/family understood their medical
conditions.
Salale University Comprehensive Document No: SLUCSH/PSI/MSOP-001
Specialized Hospital Version No: 1.0
Policy, Process and Procedures for Page: 3
discharge planning for selected NCDs Effective Date: September 5, 2025 GC
4. Medication reconciliation should be complete; logistics should be arranged; discharge
summary and return precautions should be documented and explained to the patient/families
by team of physician, nurses and pharmacist 24 hours prior to discharge.
5. Day of discharge: Clinician sign-off, nurse confirms instructions & meds, provide discharge
summary.
6. Post-discharge: Phone call follow-up within 48–72 hours for high-risk patients; clinic follow-
up.
Clinical Discharge Criteria (is individualized based on diseases condition)
• Vital signs stable for at least 24 hours.
• Pain controlled on oral meds.
• Able to tolerate oral intake.
• Ambulatory status adequate for home or support arranged.
• Investigations done or follow-up arranged.
Patient/caregiver understand medications, follow-up, and red-flag symptoms.
Salale University Comprehensive Document No: SLUCSH/PSI/MSOP-001
Specialized Hospital Version No: 1.0
Policy, Process and Procedures for Page: 4
discharge planning for selected NCDs Effective Date: September 5, 2025 GC
Processes for discharge planning for selected NCD at our hospital
Patients admitted to our
hospital for DM related
complications, DKA
/HHS/newly diagnosis
Cause/exacerbating factor identified and managed;
besides
Resolved DKA
• Clinical
• Urine ketone neg
• Anion gap normal
• Plasma glucose < 200–250 mg/dL while the patient
feeds orally
and
Resolved HHS
• Clinical
• Plasma osmolality < 300 mOsm/kg
• Plasma glucose < 200–250 mg/dL while the patient
feeds orally
• Hydration restored
Patients/families are educated about the disease and
teach back is ensured by provider
For those whom insulin is initiated by physician,
patient self-administration technique is observed to
be proper at least 10 times (new) and 5 times (known
cases)
Medications are refilled
Return precaution is informed well and follow up
arranged by liaison
Document plan as per our
hospital protocol and
discharge
Salale University Comprehensive Document No: SLUCSH/PSI/MSOP-001
Specialized Hospital Version No: 1.0
Policy, Process and Procedures for Page: 5
discharge planning for selected NCDs Effective Date: September 5, 2025 GC
Patients admitted with HTN
emergency to our hospital
Taken care of by MDT team
ICH/stroke
Encephalopathy Pulmonary edema Aortic dissection
Observe for
at least 3
days
BP <140/90 mmHg (or
BP <140/90 mmHg (or <130/80 mmmHg in BP <140/90 mmHg (or SBP 100–120 mmHg, heart
<130/80 mmmHg in CKD, CKD, DM) on oral meds <130/80 mmmHg in CKD, rate <60 bpm, stable for ≥48
DM) on oral meds for at for at least 24 hours DM) on oral meds for at hrs on oral β-blocker with or
least 24 hours least 24 hours without vasodilator.
Headache controlled with Families/patient No need for IV
oral antipain understood the Families/patient antihypertensives in past 48
Neurologic deficits are condition and red flags understood the condition hrs
stable and red flags No recurrent chest/back pain,
Families/patient Repeat imaging (if new or worsening neurologic
understood the condition deterioration) showed Pulmonary edema deficit, stable renal function
and red flags no worsening resolved (not requiring O2, test, no post op complication
Repeat imaging (if clinically stable) (if surgery was required)
deterioration) showed no No other intervention
worsening recommended by No other intervention Families/patient understood
No other intervention clinician recommended by clinician the condition and red flags,
recommended by clinician the need to avoid strenuous
Patient gaining activity and return
consciousness precautions
Discharge with
shortest possible
appointment
