NURSING PATIENT CARE POLICY & PROCEDURE
December 2, 2014
Nursing Manual (Red)
Policy #: 14.19AP
Title: Preparing a Continuity of Care Referral
for an Inpatient Discharge (Adult & Pediatric)
To describe the process for providing patient referral information for achieving
continuity of health care of patients between University of Wisconsin Hospital and
Clinics (UWHC) and American Family Children’s Hospital (AFCH) and community
health agencies and other health care institutions.
A. Electronic Health Record (Health Link) Inpatient Discharge (IP D/C) Transfer
B. Electronic Health Record (Health Link) After Hospital Care Plan (AHCP)
C. Non-Medication Prescriptions printed from Health Link
A. Determine need for patient referral.
1. For any patient discharged from UWHC or AFCH to another health care
facility (e.g., hospital, nursing home, residential facility, or correctional
institution), the Health Link IP D/C Transfer Packet (which includes the
AHCP) must be faxed in advance of the patient’s discharge. The Health
Link IP D/C Transfer Packet will also be faxed to a community health
2. In addition to the above, a referral after discharge may be:
a. Suggested by anyone, professional or non-professional, who
identifies a patient's need for continuing health care from a
community health agency after discharge from UWHC or AFCH.
b. Based on the need for continuing care, education, or ongoing age-
appropriate developmental support.
3. The suggestion for referral is communicated to the physician, nurse
providing care to the patient and the case manager. The case manager will
discuss the recommendation for a referral with patient and/or family to
obtain their permission. The case manager will then enter a recommended
order to the physician in Health Link and coordinate preparation of the
B. Prepare appropriate referral materials.
1. The case manager is responsible for coordinating completion of all
required materials in advance of discharge.
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2. The patient’s clinical provider contacts the patient’s primary care
physician to provide appropriate handoff information.
3. Information pertinent to the referral must be telephoned to the appropriate
agency before the patient is discharged. Depending on the type of referral,
the case manager, nurse providing care to the patient, team leader,
physical therapist, or the social worker would be the one calling in the
4. Refer to Nursing Patient Care Policy 14.12AP, Discharge of the Inpatient
(Adult & Pediatric), for additional Health Link documentation and
IV. HEALTH LINK IP D/C TRANSFER PACKET PROCESS
A. The case manager will be responsible for contacting involved disciplines to
ensure necessary documentation is completed in Health Link prior to requesting
the Health Link IP D/C Transfer Packet release.
B. For referrals to a home care agency:
1. There must be an order by the physician for a home health care referral
that specifies the type of skilled services needed by the patient.
2. The Justification Order (face-to-face documentation) must be signed by
the Attending Physician in Health Link.
a. The face-to-face evaluation will be performed by a physician,
nurse practitioner (NP) or physician assistant (PA).
b. The face-to-face documentation must include:
i. The Date of the face-to-face encounter
ii. That the encounter supports the need for home care
iii. The type of skilled services requested
iv. Specific clinical findings that support the need for the
skilled services requested
v. Specific clinical findings that support the patient’s
3. Be sure that it is very clear what physician(s) the home health agency is to
call for order changes or problems and include phone numbers.
C. For referrals to a nursing home, hospice, community-based residential facility, or
1. Include a signed/dictated discharge summary.
2. For discharges to a nursing home include:
a. The patient’s electronically-signed history and physical done
within the last 5 days.
b. The Discharge to Skilled Nursing Facility (SNF) Order Set (or
equivalent orders) as a part of the patient’s discharge orders.
3. For new admissions to the referral facility, a copy of patient's latest chest
x-ray report, indicating no active communicable disease, within last 90
days is required.
4. For patients being transported by ambulance, the original copy of the
ambulance prescription and a duplicate copy of the Health Link IP D/C
Transfer Packet is given to the transport company.
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D. The case manager, social worker or nurse caring for the patient will present any
additional non-Health Link information requested to the health unit coordinator
E. The nurse or health unit coordinator will print any prescriptions from the Non-
Medication Scripts section of the Discharge Navigator or the Active Orders report
and present them to the patient or responsible party in advance of the patient’s
F. Document the release of the Health Link IP D/C Transfer Packet and any
additional non-Health Link documents via Quick Disclosure in Health Link.
G. Questions should be directed to the case manager or social worker.
V. UWHC CROSS REFERENCES
A. Hospital Administrative Policy 6.37, Inpatient Health Link Downtime &
B. Hospital Administrative Policy 7.15, Discharge Planning Process
C. Nursing Patient Care Policy 14.12AP, Discharge of the Inpatient (Adult &
VI. REVIEWED BY
Assistant Director, Health Information Management
Associated Nursing Informatics Specialist, Nursing Informatics
Director, Coordinated Care, Case Management, & UW Home Health Care Services
Director, Nursing Informatics
Nursing Patient Care Policy and Procedure Committee, November 2014
Beth Houlahan, MSN, RN, CENP
Senior Vice President Patient Care Services and Chief Nursing Officer