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DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services Discharge Planning ICN 908184 October 2013 This page intentionally left blank. This booklet was current at the time
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How to fill out discharge planning discharge planning:

01
Begin by gathering all the necessary information about the patient's medical condition, current treatment plan, and any ongoing care needs. This includes collecting medical records, medication lists, and diagnostic test results.
02
Consult with the patient's healthcare team, including doctors, nurses, therapists, and social workers, to understand the specific care requirements and goals for the patient post-discharge. This step ensures that the discharge plan aligns with the patient's needs and preferences.
03
Assess the patient's home environment and living situation to determine if any modifications or additional support will be needed upon discharge. This may involve arranging for home healthcare services, medical equipment, or making accommodations for mobility issues.
04
Coordinate any necessary follow-up appointments or consultations with specialists to ensure continuity of care. This includes scheduling visits with primary care physicians, therapists, or any other healthcare providers involved in the patient's treatment.
05
Educate and provide detailed instructions to the patient and their caregivers about the discharge plan. This includes explaining any new medications, dietary restrictions, and self-care techniques that need to be followed.
06
Ensure that the patient and their caregivers have all the necessary resources and information to effectively manage the patient's health at home. This may involve providing educational materials, contact information for support services, and guidance on accessing community resources.

Who needs discharge planning discharge planning:

01
Patients with complex medical conditions that require ongoing care and supervision after leaving the hospital. This may include individuals with chronic illnesses, serious injuries, or those who had major surgeries.
02
Elderly patients who may have multiple comorbidities and additional care needs. Discharge planning is crucial to ensure a safe and seamless transition from the hospital to their home or a long-term care facility.
03
Individuals with mental health conditions who may require specialized support and follow-up care. Discharge planning helps in coordinating appropriate community resources and mental health services to promote optimal recovery and wellbeing.
04
Patients with limited social support or resources at home. Discharge planning ensures that these individuals have access to the necessary support systems, such as home healthcare services or social work assistance.
05
Anyone who has undergone a significant change in their healthcare needs or treatment plan. Discharge planning is essential to ensure that patients receive the appropriate care and monitoring post-discharge to prevent complications and promote recovery.
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Discharge planning is the process of preparing a patient to leave a hospital or healthcare facility and ensuring that they receive the appropriate care and support after discharge.
Healthcare providers, hospitals, and healthcare facilities are required to implement and file discharge planning for patients.
Discharge planning involves assessing the patient's needs, coordinating services, creating a discharge plan, and ensuring follow-up care.
The purpose of discharge planning is to ensure a safe and smooth transition for patients from the healthcare facility to their home or another care setting.
Discharge planning must include the patient's medical history, current health status, medications, treatment plan, follow-up appointments, and any necessary support services.
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