Completion of a patient’s and family’s stay in a hospital facility.
Objectives:
– To ensure a continuity of care (Interrelation specialized-primary care). – Assess the patient’s care needs after hospitalization and promote readaptation to their environment. – To ensure that the patient and family have the knowledge and skills for self-care and that they can control the situation at home (pharmacological treatment, diet, controls, special care).
Equipment:
– Means of transport appropriate to the patient’s needs (wheelchair, stretcher, etc.), if applicable, to the transfer vehicle.
Material:
– Medical and nursing report at discharge. – Medication and treatment material, if required. – Authorized ambulance form, if applicable.
Procedure:
1. Needs assessment and problem identification.
– Determination of home care. – Assessment of nursing care needs. – Assessment of physical and psychological limitations and coping mechanisms. – Assessment of the patient’s physical environment. – Assessment of social support.
2. Preparation for the patient’s discharge.
– Inform the patient and family sufficiently in advance of discharge, the expected day and time. – Communicate the patient’s discharge to the admission service, pharmacy, and kitchen. – Arrange for ambulance if the patient’s condition requires it.
3. Registration and documentation of discharge.
– Discharge nursing report. – Report on nursing methodology (patient assessment at discharge, care planning and discharge recommendations). – Assess the patient’s sociocultural perspective for planning cultural care.
4. Execution of the discharge
– Check that no complications have occurred that would prevent discharge. If so, notify the physician. – Help the patient to collect his or her belongings and hand over the personal belongings and valuables deposited. – Give the patient the nursing report at discharge and verify that the patient has all the documentation needed: discharge medical report, outpatient appointments, home oxygen form, ambulance form, etc. – Make sure that the patient has understood all the recommendations and instructions. Repeat as many times as necessary. – Transfer the patient according to the means of transport needed (notify the cellphone and ambulance). – Send the medical record to the administrative staff for filing.
5. Picking up the material and tidying up:
remove clothes and personal utensils, notify the cleaning service, and prepare the room for new admission.
6. Notify the admission service of bed availability.
– Observations: VOLUNTARY DISCHARGE – Make sure that the patient understands the situation and signs the form, if he/she does not want to sign, it is reflected on the record. – Persons without legal capacity cannot sign the voluntary discharge form; their guardians sign. – If the admission is judicial, the discharge is given by the judge.
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