Date
of Last Review 10/13/08
SME: Director of Social Services
The following are responsible for completing the discharge documentation:
 | The resident and/or attending physician |
| The social service clinician |
| Nursing staff |
The resident and/or attending physician complete the computer fields for the "Discharge Summary" that includes the following:
| Discharge Date and Global Assessment of Functioning (GAF) score |
| Information on the facility to which the patient is being transferred |
| Psychiatric Diagnoses: Axes I and II from current DSM |
| Medical Condition(s) on Axis III of the ICD9 |
| Current Status of any Medical condition |
| Relevant Laboratory Data |
| Discharge Medications and Dose |
| Inadequate Outcome Concerns, Recent Seclusions, Self Care Needs |
| Physician's Long Term Recommendations including Medications Known to be Ineffective |
Discharge day : The resident and/or attending physician sign the medical record copy of this document on the day of discharge.
The social service clinician is responsible for the following:
| Updating the computerized patient file under Social Services Aftercare by noting in the appropriate fields as follows: |
 | The Discharge Status Type |
| The Primary Aftercare Type, the Facility Name, and the appointment date and time |
| Secondary Aftercare Type and Facility Name |
| Information about the discharge residence as follows: |
 | Facility Type |
| Living Arrangements |
| Writing in the progress notes a brief Discharge Summary with an overview of final discharge plans. |
A Registered Nurse completes the Discharge Instruction on all patients prior to discharge.
The Discharge Instruction is accessed upon data entry and includes the following discharge information:
| Summary of care provided |
| Discharge medications |
| Healthcare teaching |
| Contact doctor/Clinic if you... |
| Medical follow-up care |
| Discharged to/Accompanied by... |
| Mode of transport from unit |
The Registered Nurse reviews the instruction for content with the patient/family/significant others, and obtains the signature of the patient/guardian on both copies.
The patient/family/significant other/continuity of care provider receives a written copy of the discharge instruction and a copy is retained in the medical record.
An entry in the progress notes is not required if the automated Discharge Instruction is complete. However, additional information may be captured in the Progress Notes.
The resident or attending physician completes a Discharge Summary on the day of discharge, or dictates "information not available."
In Item 7 of the Discharge Summary, the physician provides the following information:
| All pertinent information on prescriptions given to the patient on discharge |
| Appointments made for the aftercare of the patient, |
Related to regulatory standards
If you have questions regarding the content of this site please contact the Policy and Procedure Committee. If you experience any technical problems please contact the MIS Department.
