Discharge planning in nursing can be a challenge, especially when you’re a new nurse trying to juggle multiple patients, discharge orders, and everything else happening during your shift. I’ve discharged many patients since I became a nurse in 2010 and I’ve learned a few things that make the process go a lot more smoothly.
Now, we’ve all heard that old nursing saying: “discharge planning begins on admission” – but what I would like to focus on is day-of discharge planning, not big picture discharge planning. Meaning, you’re the patient’s primary nurse and he or she is going home today. What do you do?
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Discharge Planning Tips for Nurses
Let’s go over what you practically need to do to get your patient successfully discharged during your shift, whether that means to their home, an extended care facility (ECF), skilled nursing facility, rehab, or somewhere else. A successful discharge includes everything from timing to transportation and even prescription help.
While this article won’t feature a specific discharge plan example, it will prepare you to build your own. It’s actually quite difficult to share one since most hospitals have an EMR system that facilitates nursing discharge planning right alongside your daily care. You might not even realize you’re working on the nursing discharge plan as you answer pertinent questions as you chart. They are also usually very lengthy and customized to a specific patient’s needs as they are based on a specific diagnosis, care instructions, medications, and the required follow-up.
Assess Your Patient’s Discharge Needs
When developing the patient’s discharge plan you must put first things first, and in the nursing process that is always an assessment.
Figure out during the report which patients are being discharged and ask some specific questions, either directly to the patient, the off-going nurse, or by looking in the chart.
- Where will they be discharged to?
- Home, nursing home, rehab, etc.
- Are there any tests (labs, x-rays, scans, evaluations) that are must be completed before discharging
- For example, the patient may be a possible discharge pending a transthoracic echocardiogram, chest x-ray, follow-up basic metabolic panel (BMP), or some other test.
- Will they need anything set up?
- Home care, in-home therapy, DME (stands for durable medical equipment, so things like walkers, shower chairs, blood glucose monitoring supplies)
- What kind of transportation will they have?
- Are there any financial concerns?
- Do they need any extensive teaching?
- Patients going home with a blood sugar monitor for the first time, on a new blood thinner, after major surgery, or with a new diagnosis like congestive heart failure will require more time to educate them and answer more questions than others
Knowing these things early in the shift is important because they can really impact your time management. You may need to expedite tests in order to facilitate a timely discharge, need to set up transportation, get specific orders from the physician, and so forth.
The Inevitable Question: What Time Will My Patient Be Discharged?
“So, the doctor said I may go home today. What time will that be?”
Without fail, almost every single patient being discharged wants to do know when. I completely understand, however it’s not that straightforward. Don’t let this question screw up your nursing discharge.
For patients to get discharged, the attending physician must write discharge orders. This means they’ve got to sit down and put all of the medication orders in correctly, sign any printed prescriptions for narcotics, and a few other things.
My go-to answer is something like this:
“So, to get you discharged, the physician has to enter quite a few things into the computer. Things like follow-up appointments, specific things they want you to do or not do, medication changes, prescriptions, and more. Once this has been done, I can complete your discharge. Typically, I tell patients to plan for an early afternoon discharge. This gives the physician time to decide on and enter the information. Sometimes it happens earlier, but mentally planning for an early afternoon discharge time is the most realistic.”
If people are looking for a specific time to facilitate a ride, I’ll tell them between 2-3 pm.
Physicians typically round on ALL of their patients, then sit down and write discharge orders. What I see happen a lot is the physician rounds around 9:00 am or so and says they can go home but doesn’t usually put discharge orders in until around 1:00 pm.
By telling people between 2-3 pm, that gives me enough time to compile the discharge paperwork, correct any errors, address any deficits, facilitate prescriptions, and balance it with my other patients discharging the same day as well.
It is especially important to give yourself ample time if a patient is being discharged to another facility and is being transported by ambulance, medic, or some other transportation service.
Work With Case Management and Your Nursing Team
With nurse discharge planning, I typically rely heavily upon my case managers. They’re amazing getting things set up with facilities, DME, etc.
Also, for a patient to get things like outpatient physical therapy and/or occupational therapy, some forms of DME, or to go to a specific type of facility (like rehab), CMS usually requires there to be a note from therapy saying the patient requires such. Therefore, touch base with your physical therapist and occupational therapists and read their notes to get a better idea of what they’re recommending for your patient.
Tip: If your patient says they want something specific (a cane, walker, shower chair, to go home and not rehab or vice versa) look at the latest notes from physical and/or occupational therapy and see what they recommend.
Also, make sure to check out the latest notes from case management (CM) and social work (SW) as well. They typically document any facilities they’ve sent referrals to, if the patient has been accepted, who you need to call report to, the time of transportation, etc. Don’t make my rookie mistake of calling CM or SW before simply looking in the chart! It can save you (and them) time if you take a look at their notes before paging/calling.
Think About Discharge Transportation
Asking about this first thing will save you quite a bit of headache. Sometimes, the person who will bring them home is already sitting in the room, but most likely they’re going to have to call for a ride. Maybe their ride can only come during a certain period of time, or only after a certain time, or can’t come at all and we’ve got to find a ride.
I’ve gotten everything together for a discharge, only for the patient to tell me (at 5:00 pm after CM has left for the day) that they have no way home. I’ve also been ready to discharge a patient and they tell me they can’t get a ride until tomorrow.
Ask early so you can plan appropriately!
Help Patients with Paying for Prescriptions
This can be another big headache if you haven’t asked the right questions or planned for it. Multiple times, I’ve created all of my discharge instructions and the patient is ready to walk out the door and suddenly they tell me they can’t afford their prescriptions.
This is where your case manager can be a HUGE help! If your patient is concerned about paying for their prescriptions, get case management involved as early as possible. They can help navigate insurance coverage issues, identify potential financial assistance resources, and work with the appropriate members of the healthcare team to figure out what options are available.
Sometimes the issue isn’t that the patient can’t afford any medications. It’s that one of their new prescriptions is ridiculously expensive, isn’t covered by insurance, or requires prior authorization. Your case manager can help coordinate with the pharmacy, provider, or social worker to see what can be done before the patient leaves.
And don’t assume that because a patient has insurance, they’re going to be able to afford their medications! Copays can add up quickly, especially when someone is going home with several new prescriptions.
The important thing is to identify these concerns EARLY. You don’t want to spend all day getting everything ready for discharge only to find out the patient can’t get the medications they need once they get home.
As the discharge nurse, it’s also important to make sure the prescriptions get to where they need to go. Double-check that the discharging provider has sent the prescriptions to the correct pharmacy, and follow your facility’s policies for any medication-related discharge requirements. If there are concerns about whether the patient will actually be able to obtain their medications, work with case management and the healthcare team to address those barriers before discharge.
Paperwork, Paperwork, Paperwork
Make a list and check it twice.
Seriously.
There are typically quite a few things you have to enter into the computer for the patient, but also for your documentation as well. Care plans need to be closed out, education needs to be resolved, IVs and telemetry need to be removed and documented, documentation requirements need to be met (like core measures), the next dose due for each medication needs to be indicated, and more.
If the patient is being transferred to another facility, even more, needs to be completed. These things include calling reports to the receiving facility, printing and faxing additional paperwork, printing information for whoever is transporting the patient, and so forth.
Write yourself a little list and check it off as you complete tasks so that you do not forget them.
Giving Discharge Instructions to Your Patient
Before sitting down to give instructions, double-check that the information is correct, paying particular attention to follow-up appointments, medication due times, prescriptions, and any important teaching points that need to be included.
Going over instructions can be pretty overwhelming for patients and should not be rushed. If you’re able, grab a chair and sit down next to them. That lets the patient know you’re not just going to quickly go through it and run out the door (even if that’s what you want to do!) and allows them to more time to ask clarifying questions without feeling like a burden or bother.
One thing that can really help is using the teach-back method. Rather than asking, “Do you understand?” (because most patients will say yes!), ask them to explain an important instruction back to you in their own words. This can help you identify anything that needs a little more explanation before they head home.
Remember the potential mental state of someone going home from the hospital. They may be overwhelmed, excited, sad, tired, scared, or any combination thereof. Therefore, make sure all important information is written down. They will forget a lot of what you talk about during discharge instructions and you must have something to refer back to.
And finally, make sure you have included phone numbers for follow-up questions. They need to have the phone number of someone they can call with concerns both during and after office hours. This will prevent follow-up phone calls to the nursing unit, but also will facilitate the patient speaking to their physician’s office – which is who they should be speaking with for follow-up questions and/or concerns.
Final Thoughts on Discharge Tips for New Nurses
Discharge planning in nursing is one of the most critical aspects of patient care because it ensures that patients have what they need to go home and recover well, live healthy lives, and prevent readmission.
Here are some key things you need to remember to ensure your nursing discharge planning is successful:
Assess needs early on so you can manage your time while addressing their needs, provide realistic expectations related to timing, leverage your healthcare team, ensure transportation is secured, make sure they can afford their prescriptions, make sure your paperwork and documentation is complete, and take your time while giving discharge instructions.
It sounds like a lot, but you will get used to the process and develop your own discharge routine!
More Resources for Med-Surg Nurses
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- What Do Med-Surg Nurses Do?
- Nursing Time Management Tips
- Code Blue! Surviving Your First Code Blue or RRT
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Thanks for sharing the tips for new nurses.
Thank you for sharing. Your info & insights are very helpful to a less experienced RN.