Discharge from the hospital is the point at which the patient leaves the hospital and either returns home or is transferred to another facility such as one for rehabilitation or to a nursing home. Discharge involves the medical instructions that the patient will need to fully recover. Discharge planning is a service that considers the pa tient's needs after the hospital stay, and may involve several different services such as visiting nursing care, physical therapy, and home blood drawing.
Hospitalization is often a short-term event, so planning for discharge may begin shortly after admission. The physicians, nurses, and case managers involved in a patient's care are part of an assessment team that keeps in mind the patient's pre-admission level of functioning, and whether the patient will be able to return home following the current hospital admission. Information that could affect the discharge plan should be noted in the patient's medical record so that it will be taken into account when discharge is being scheduled. The primary questions include:
Can this patient return to his or her preadmission situation?
Has there been a change in the patient's ability to care for him- or herself?
Is the patient in need of services to be able to care for him- or herself?
Which services will the patient need?
Are there mental health needs that must be met?
Does the patient agree with the discharge plan?
While a person has been in the hospital, physicians other than the primary care physician have been in charge of the patient's care. Good discharge planning involves clear communication between the hospital physician(s) and the primary care physician. This may be done by telephone and/or in writing.