171 Ashley Ave.
Charleston, SC 29425
843-792-1414
800-424-MUSC
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October 2008
Clearly, no matter how well we take care of the seriously ill patients in the hospital, their overall care will be significantly compromised if a successful transition to the outpatient setting does not take place. First and foremost to that transition is for the physician to begin planning for discharge many days prior to when it will occur, typically at the time of admission. The planning involves coordination of all the services the patient will need post-discharge, as well as assuring education of the family and their post discharge providers takes place. So the question arises, what are the key components for the physician to assure a smooth transition occurs? There are many important things to consider but the first steps revolve around communication:
- Communication with the nurses, staff and discharge coordinator to ensure that follow-up appointments are made, and that the patient/family receives appropriate training and education for post-hospital care (e.g. - medication, dressing changes, other therapies and follow-up appointments).
- Communication directly with the patient/family to assure they understand what was wrong, what their treatment was, and the instructions/training they have been given by the staff.
- Communication with the outpatient providers to assure that they are familiar with and have documentation of the key features of the patient's hospitalization.
The first two items take listed above take place during the few days prior to discharge and must be guaranteed by directly querying the patient/family during the 12 hours prior to discharge on whether they understand the key features of their post-discharge care. The last item must also occur in the last few hours of admission. Written communication is critical and should occur in the form of a preliminary discharge form which summarizes the diagnoses, key treatments received, medications and follow-up visits. A survey of our referring physicians revealed that the community providers prefer this form be faxed to their offices, but in some cases electronic posting is acceptable. For select patients, a phone call to the key follow-up physicians may be useful as well.
Finally, it is the attending physician's responsibility to assure that a full discharge summary is completed. It should detail the history, condition upon admission, hospital course, and instructions for care once the patient is discharged.
Attending physician can be thought of as the "CEO" for the patient's admission, directing and coordinating care with all the care providers in the hospital and those that will assume care post-discharge. It is primarily through this process of communication that most of these activities take place, assuring a smooth discharge transition occurs.
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J. Philip Saul, MD
Medical Director
Director, Pediatric Cardiology |
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