What should the nurse present in the Discharge planning? This is one of the most commonly asked questions. The information to include should be in line with the care of a nurse provides to the patient, the level of care a nurse can provide and the level of communication between the nurse has with the patient. The purpose of this article is to guide nurses through the process of what documentation should be included in discharge planning. We will also look at other issues which may need to be considered.
In short, all documentation that helps to demonstrate the quality of care provided should be in place. All documentation that does not assist in this process needs to be deleted. This includes but is not limited to notes on the assessments carried out. Any pre-planning discussions between the staff and the patients need to be documented. Any reference to treatment that was done by another nurse needs to be documented. If the nurse wishes to add any additional comments during the care giving process, they should do so.
A good nurse is going to want to teach their patients how to care for themselves. Good documentation does this. A nurse should provide a discharge instruction/process manual as part of the documentation process. This will help nurses show their patients how to take care of themselves following their discharge. If a nurse is unclear about what documentation is required for the different stages of care after the patient has left the hospital, they need to clarify from the outset.
There are some situations where good quality documentation is not needed. For example, the documentation process for waiting times is generally not required. In these circumstances, the nurses themselves will manage the documentation process. In addition, there is no need to collect other information that is not directly relevant or needed for the purpose of monitoring the patient’s condition. Such information needs to be managed at the point of care by someone who is trained and experienced in nursing care.
There are situations where a nurse may need to collect other information that is of less importance to them. They need to collect this information for example when they need to enter the information into the system to capture data or when they need to write it down for reference purposes. However, these situations are relatively rare and in any case would require less documentation than what is usually required. For example, the most important piece of documentation which could be needed would be the discharge summary that tells the caseworker what happened to the patient and when they should expect to see them back in the ward.
What happens if a nurse collects non-related information which is needed for the documentation process? In general, these types of information are collected at the time of admission. The most common reasons for this would be to determine how well the patient is receiving care and also to make a list of any medications that must be stopped while the patient is admitted. This information is also likely to be necessary for an inquiry that may follow once the patient has been discharged.
The nurse may be asked to describe the situation and explain what they thought happened as well as what happened during the period that they left the hospital. This type of information needs to be documented clearly so that it can be used later on either by yourself or a later team of caseworkers if there is an inquiry that needs to follow up on the discharge. Again the details of what was said may not always be important.
The last area in which the documentation process may need to be considered is the referral. A nurse makes a referral when they believe that a particular patient requires further assessment or care. In some cases, a nurse will want to refer themselves out to a specialist in a specific area. Again, the documentation can relate to what was said in the documentation or it may be the case that the nurse wants to follow up on the referral that was made by another nurse. In these instances, the documentation is an opportunity to record details related to the referral.
