STANDARD 12: Planning, Admission and Discharge

12.1 General

1. The healthcare organization shall have documented processes to obtain and control information relative to patient:

a) pre-admission;

b) admission;

c) plan of care (see STANDARD 9.5);

d) discharge planning.

2. Outputs shall become part of the patient medical record (see STANDARD 23).

3. In the admission and discharge process, the healthcare organization shall screen, identify, and re-evaluate high-risk patient likely to require special care related to:

a) functional status;

b) cognitive ability of the patient;

c) family support and in-home care;

d) psycho-social needs relative to the admitting diagnosis.

4. Evaluation of the above processes shall be required as per STANDARD 4.

12.2 Planning and Admission

1. All admission shall be on the direct order of a credentialed medical staff member or their legal agent.

2. The healthcare organization shall ensure that this process defines:

a) a system for multistage patient identification using healthcare organization generated documents (wrist band, etc.), patient provided name and birth date, or other reliable methodology including third party identification if necessary;

b) patient identification as defined above shall be determined and confirmed prior to any admission and/or process within the healthcare organization.

3. The healthcare organization shall provide patients and/or family a documented list of patient rights (see 11.1.2.) and be responsible for answering all question prior to admission except by waiver or in case of emergencies.

4. The healthcare organization shall screen and identify all high-risk patients who are likely to require post discharge care in specialty or other step-down facilities at an early stage of admission, and/ or pre-admission.

NOTE 1 In some cases, process timing may be exceeded subject to the availability of specific specialty consultation on a patient.

12.3 Discharge

1. The healthcare organization shall provide a discharge planning evaluation to the patients upon the patient’s request, the request of a person acting on the patient’s behalf, or the request of the physician.

2. A registered nurse, social worker, or other LIP shall develop and supervise the development of the evaluation.

3. The healthcare organization’s ability to meet discharge planning requirements shall be based on the following:

a) implementation of need for individual patients including those identified with high-risk criteria;

b) maintenance of a file on community-based services and facilities including long term care, sub- acute care, home care or other appropriate levels of care to which patients can be referred;

c) coordination of the discharge planning evaluation among various disciplines responsible for patient care;

d) patients are included in the planning of their discharge or referral (See 12.4).

4. Discharge planning personnel shall complete their duties in a timely manner.

5. Discharge planning personnel shall discuss the results of the evaluation with the patient or individual acting on his or her behalf. Results of this conversation shall be noted in the medical record. When ethically possible, all questions from the patient or family shall be addressed.

6. The healthcare organization shall have a mechanism in place for ongoing reassessment and evaluation of its discharge planning process which shall be reported to the healthcare organization management system. The reassessment shall include a review of discharge plans to ensure that they are responsive to discharge needs.

NOTE 1 Ideally, discharge planning will be an interdisciplinary process, involving disciplines with specific expertise, as dictated by the needs of the patient. For example, for a patient with emphysema, the discharge planner could coordinate respiratory therapy and nursing care, and financial coverage for home care services and oxygen equipment, and patient/caregiver education utilizing cost effective, available community services in an expedient manner.

12.4 Patient Transfer or Referral

1. When required the healthcare organization shall transfer or refer patients to appropriate facilities, other departments or units, agencies, or outpatient services, as needed for follow-up or ancillary care. The healthcare organization shall consider:

a) escort for the patient;

b) essential medical history;

c) medications;

d) essential equipment;

e) verbal/written handover requirements;

f) any other relevant information regarding the patient’s current status;

g) other documentation requirements.