Post Discharge Scenario

Patients recently discharged from acute care back to the community are at an increased risk for hospital re-admission (3). Efficient collaboration between interdisciplinary health professionals and nurse liaison can improve discharge planning processes.

Discharge planning is used to create a plan of care for a patient who is leaving a care setting. An evaluation is done to determine the patient’s continuing care needs once they have left the care facility. When patients are send back home or to a facility that does not require full time nursing care assistance, programs need to be put into place to ensure that the patient is receiving the proper continuation of care post discharge. Proper discharge planning can decrease the chances of a hospital readmit, help in recovery, ensure medications are prescribed and given correctly, and adequately prepare family or caregivers to assume proper post discharge care. According to the Family Caregiver Alliance, “It is important, not only for patients, but family

The history and physical report is usually the first document to help a physician determine a diagnosis and begin to help the patient get better. The missing section of the given HP form is the chief complaint. The chief complaint forms the second step of medical history taking, and is a concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the visit. This is a statement in the patient’s own words.

This week’s reflection paper focuses practice-based evidence and the operation of the theoretical framework of person-in-environment as each relates to discharge planning at UMPC Mercy Detoxification Unit (UPMC-MDU).

The hospital that I worked for while working as a case manager was not in network with Kaiser Permanente. It was also the time when the hospital started to hire hospitalists to manage patient care while they are a patient in the hospital. It actually worked out because it filled in the gap in patient care. The hospitalists were acting as the patient's primary care provider. Kaiser as with many other insurance have a case manager designated to ensure that the patient is meeting criteria not only for an inpatient hospital stay but for the level of care they are receiving as well such as ICU, Stepdown, or Med-Surg. I would have to give them an updated clinical information daily or every 3 days depending on the severity of illness. As a case manager, I was responsible for discharge planning and I preferred to transfer the patients to

When she sees a patient for the first time she talks to them about the doctor’s report and asks specific questions about their injury or experiences leading up to the need for physical therapy. Megan explained how important it is to make the patient feel comfortable and keep a positive attitude towards the patient’s recovery. These consultations were the most interesting to sit in on because it allowed me to observe the therapist’s ability to take the patient’s information and create a diagnosis and treatment plan for the injury or pain described. Megan may have multiple patients at a time so she stressed the importance of keeping up with each patient and why the physical therapy techs are so helpful. Scheduling is another job of the therapists that is important in keeping the clinic running smoothly. There is also paperwork that has to be filled out for every patient after every visit about their

Ineffective discharge teaching often leads to unnecessary admissions to the hospital resulting in negative patient outcomes and decreased patient satisfaction. This negatively impacts the well-being of the patient and creates a financial burden on institutions. As a result, this universal practice issue requires a call to action on the part of the nursing profession. Nurses can proactively assist in assuring incidents of readmission do not occur. Nurses as educators play a critical role in the successful transition of patients from hospital to home. The overall goal of discharge education is to ensure there is an exchange of critical information between the patient and nurse in which plans of care are understood and followed. The research

Mr. P is an 88-year-old man who was admitted to hospital after falling outside his home on an uneven sidewalk. He underwent a successful hip replacement surgery and has begun his rehabilitation on an acute care surgical unit. Mr. P’s 61-year-old son and daughter-in-law visit him frequently while he has been hospitalized, but they are unable to care for him after his discharge from the hospital. The physical therapist feels that Mr. P cannot adequately care for himself at home. (Fero, Herrick, & Hu, 2011, p. 113)

This paper focuses on the discharge plan for patient who underwent the Total Hip Replacement (THR). The nurse, as a case manager, works with the multidisciplinary team to determine the appropriate discharge plan for the patient. The roles and responsibilities of each member are elaborated. The healthcare issues, the safety assessment are discussed. In this case study the patient lives alone during the recovery from the surgery, so the effects of social isolation and psychological factors on the recovery process are also explained.

In this scenario, the physiotherapy team will decide what the most appropriate care for Mr Robinson will be. They will report back to the interprofessional team so that treatment can be integrated and reported on within the care plan. Whilst on placement I witnessed this on a daily basis. Following handover the Sister would meet with a senior member from each team, including the therapists and commence ward rounds. This provided all disciplines with an update of progress, changes that may have occurred overnight and

This study demonstrated the effect of post-discharge phone call on enhancing patients’ perception of both hospital and physician. Notably, the physicians’ call is more effective for improving the hospital and physician satisfaction for younger patients than older patients, given the only difference is the age (The baseline confounders such as marital status and race are controlled). If the patient’s age is older, receiving phone call from physician can decrease the likelihood of satisfaction with hospital and physician. The main effect of phone call is biggest for youngest patients. This finding shed light on how hospital management board and physicians can provide patients with more comfortable experiences when implementing phone-call intervention

This patient needs an interpreter for Spanish to assist with discharge instructions. He needs to be informed of the medications the MD discontinued, new meds that are ready to pick up at his pharmacy, the co-pay involved for those medications, proper administration of the medications, side effects and when to call the doctor if there are any adverse effects. He also needs to be taught the importance of fluid restriction to 1500mL/day. This includes water, ice, gravy, soup, ice cream, dairy, soda or other fluids. He needs to be shown an example of how much 1500mL of fluid looks like and taught the importance of daily weights. This patient did not have a scale at home, so he needs to be informed that there are scales available for low cost at a local store. Dietary restrictions of potassium, calcium, phosphorus and protein should also be addressed. He

Mr. Trosack is a 72 year old man who fell down a long flight of stairs a month ago, underwent a total hip replacement and is in need of a discharge plan. He completed two weeks of rehabilitation in the hospital for his hip as well as diabetic teaching for his new onset of Diabetes. It was also discovered during this hospitalization that he needed to start taking medication for hypertension. Both he and his family are in denial about what it will take to get him home and deliver the care that is needed.

Using the seven key principles of the hospital discharge process devised by the Department of Health (DH, 2003), this case study will critically analyse the process of an elderly patient who was discharged from a local acute trust. It begins by providing a definition of discharge planning, before providing a brief biography of the patient, including a rationale of why this patient was selected, details of her past medical history, reason for current admission, any issues raised and details of any care provided. Throughout this case study, in accordance with the Nursing and Midwifery Council (NMC, 2008) and the Data Protection Act (1998), the patient shall be referred to as Mrs. Blue to maintain anonymity. Although the

Discharge Planning – Patients who require continuing care after release from the hospital are identified and the appropriate services are arranged through participating home care, medical equipment and other providers.