Participate in a multidisciplinary team to coordinate discharge planning efforts. The team may include the bedside nurse, social worker, care manager, respiratory therapist, nutritionist, and pulmonologist.
Determine the appropriate post-hospital setting to which the patient should be discharged.
Assess patient and family understanding of the diagnosis, treatment, prognosis, follow-ups, and warning signs for which to seek medical attention.
Assess the patient's level of independence prior to admission.
Evaluate how the patient's current illness will impact his independence.
Identify the patient's formal and informal supports.
Identify the patient's and family's goals, preferences, comprehension, and concerns about discharge.
Confirm arrangements for transportation to initial follow-ups.
Assess/confirm the patient's and family's understanding of prescribed medication, including dosage, administration, expected results, duration, and possible adverse effects.
Assess/confirm the patient's ability to obtain medications; identify the party responsible for obtaining medications.
Ensure that patient and caregivers have been given medical contact information.
Provide information on smoking cessation, if appropriate.
Provide contact information regarding local support groups or services.
Document the discharge planning evaluation in the patient's clinical record, including who was present/involved in discharge planning and teaching. Document patient understanding of teaching provided and whether follow-up teaching is needed.