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Discharge of the Inpatient (Adult & Pediatric) (14.12)

Discharge of the Inpatient (Adult & Pediatric) (14.12) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Unit Operations

14.12


NURSING PATIENT CARE POLICY & PROCEDURE





Effective Date:
December 2, 2014
Amended July 30,
2014

Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 14.12AP

Original
Revision

Page
1
of 4

Title: Discharge of the Inpatient (Adult &
Pediatric)

I. PURPOSE

To prepare the patient, family and/or other individuals for a patient's return home or
discharge to a post acute care facility.

II. POLICY

All patients will be assessed for discharge needs at the time of admission and throughout
the hospitalization to ensure that the patient’s needs are met and that he/she can be safely
transitioned to the next level of care. There is a required handoff of referral information
that must accompany patients referred to any post-acute care provider. Refer to Nursing
Patient Care Policy 14.19AP, Preparing a Continuity of Care Referral for an Inpatient
Discharge (Adult & Pediatric).

III. FORMS AND EQUIPMENT

A. Electronic Health Record (EHR) (Health Link)
B. Discharge Folder
C. Discharge Passport

IV. PROCEDURE

A. The physician and case manager are responsible for maintaining the anticipated
discharge date in the patient’s clinical record.
B. Once Discharge Orders Have Been Written (Refer to Hospital Administrative Policy
7.15, Discharge Planning Process):
1. The Health Unit Coordinator (HUC)/Patient Care Technician (PCT)* has the
following responsibilities:
a. Schedule post-discharge diagnostic studies and clinic appointments
as indicated in the discharge orders. UW Health appointments can
be scheduled via the In-Basket method and phone. Appointments
scheduled in the patient’s clinical record will display in the After
Hospital Care Plan (AHCP) when scheduled by a UW Health
clinic.
b. If the patient needs to schedule follow-up appointments with a
non-UW Health provider, enter the appointment details in the
Appointments Scheduled at Outside Facility print group of the
AHCP report in the patient’s clinical record.

Page 2 of 4

c. If there is not a HUC/PCT present on the unit at the time of
discharge, the next HUC/PCT on duty is responsible for assuring
that post discharge appointments are made via the In-Basket
method.
d. Phone or fax may be used to schedule appointments if a clinic is
not using In-Basket, an appointment requires coordination of
multiple areas or services, or the electronic health record is down
(see Hospital Administrative Policy 6.37, Inpatient Health Link
Downtime & Recovery).
e. Prepare the Discharge Passport and place in the Patient’s
Discharge Folder.
f. Notify Pharmacy, Environmental Services and other disciplines as
needed with the anticipated hospital discharge date.
2. The nurse providing care has the following responsibilities:
a. Ensure that the discharge plan is appropriate to meet the needs of
the patient and that the patient/caregiver is capable of following
through with the plans and appointments. Although the case
manager is accountable for the coordination of the discharge plan,
there are times when a case manager is not available at the time of
discharge and/or the patient's needs may have changed.
b. Review discharge plans with the patient/caregiver and confirm
transportation arrangements.
c. Review the AHCP with patient/caregiver including treatments,
diet, activity restrictions, use of equipment as indicated, post-
discharge appointments, the Discharge Passport process, and any
other discharge instructions. The pharmacist and nurse share
responsibility for reviewing the medication profile with the patient.
d. Ensure that all IVs and other invasive devices that are to be
removed prior to discharge are removed and appropriately
documented in the patient’s clinical record.
e. Ensure that all teaching provided is documented in the patient’s
clinical record and printed as needed.
f. Ensure all physiologic monitoring data is validated in the patient’s
clinical record.
g. For patients being discharged to Skilled Nursing Facilities,
complete the nurse-to-nurse telephone handoff phone call and
document in the patient’s clinical record. Complete nurse-to-nurse
verbal handoffs to other agencies or facilities as appropriate.
C. Before Patient Leaves the Unit (Refer to Hospital Administrative Policies 7.15,
Discharge Planning Process and 7.27, Management of Patient Belongings).
1. The physician will complete the Discharge Order.
2. The nurse providing care has the following responsibilities:
a. Complete and assure accuracy and completeness of the AHCP.
b. Review the completed AHCP with the patient or responsible party
and provide them with the final up-to-date copy. The AHCP can be
printed after Pharmacy has completed their final discharge
medication patient teaching.
c. Print any non-medication prescriptions from the Discharge
Navigator and provide to the patient or responsible party.

Page 3 of 4

d. Determine whether patient has all belongings and document in the
patient’s clinical record. Give patient or responsible party a copy
of the Patient's Valuables Form to obtain items deposited in
Admissions as applicable. Accompany or assist patient to
Admissions if necessary. Refer to Hospital Administrative Policy
7.27, Management of Patient Belongings.
e. When needed, a staff member will accompany patient to vehicle
and assist. For nursing units with an organized volunteer program,
if deemed appropriate by clinical staff, a designated unit volunteer
may accompany the patient to his/her vehicle. Volunteers should
only accompany patients who can ambulate independently, are
able to transfer independently from a wheelchair to a car, or do not
need to be positioned in a car seat.
D. After the Patient Leaves the Unit
1. The nurse providing care has the following responsibilities:
a. Provide the HUC/PCT* with bedside forms and discharge
paperwork.
2. The HUC/PCT* has the following responsibilities:
a. Enter the discharge date and time in the patient’s clinical record.
This should be done within two (2) minutes of the patient leaving
the unit. Failure to discharge the patient promptly can result in
delays for new admissions. The date and time must reflect the
actual time the patient left the nursing unit. Include comments as
required (i.e., return to clinic appointment times/dates, name of
nursing home, time patient left unit, care level, etc.).
b. At UWHC, the EHR discharge transaction triggers a bed cleaning
request for Environmental Services. STAT bed cleaning requests
should be relayed to the Access Center (263-6796). The Access
Center will initiate the STAT cleaning request to Environmental
Services.
c. For discharges during the EHR downtime, complete the
appropriate downtime forms and tube to Bed Control/Reservations
to notify them of the discharge.
d. At TAC, the EHR discharge transaction triggers a bed cleaning
request for Environmental Services. STAT bed cleaning requests
should be relayed to the Control Center at 608-440-6666. The
Control Center will initiate the STAT cleaning request to
Environmental Services.
e. For discharges during the EHR downtime, complete the
appropriate downtime forms and tube to Control Center to notify
them of the discharge.
f. Disassemble the clinical record according to the Inpatient Clinical
Record Filing and Discharge Chart Order.
g. Remove labels from door, chart holder and other information
boards.
h. Place any outside imaging studies, whether hard copy or electronic
media (e.g., CD ROM) with the disassembled patient chart, for
pick-up by Health Information Services.


Page 4 of 4

* When a HUC/PCT is not present on the clinical unit, functions designated to be
performed by the HUC/PCT will be performed as delegated by the Care Team Leader or
her/his designee.

V. UWHC CROSS REFERENCES

A. Hospital Administrative Policy 6.37, Inpatient Health Link Downtime & Recovery
B. Hospital Administrative Policy 7.15, Discharge Planning Process
C. Hospital Administrative Policy 7.27, Management of Patient Belongings
D. Nursing Patient Care Policy 14.19AP, Preparing a Continuity of Care Referral for an
Inpatient Discharge (Adult & Pediatric)

VI. REVIEWED BY

Director, Access Services
Director, Coordinated Care, Case Management and UW Home Health Care Services
Director, Nursing Informatics
Program Director, Transitions of Care
Director, Professional Services UW Health at The American Center, June 2015
Nursing Practice Council
Nursing Patient Care Policy and Procedure Committee, November 2014

SIGNED BY

Beth Houlahan, DNP, MSN, CENP
Senior Vice President Patient Care Services and Chief Nursing Officer