SURG - Discharge

Study Notes

Patient must meet certain goals before discharge, including eating and drinking on their own, being symptom-free, tolerating diet, having return of bowel function, having pain controlled, and being able to ambulate and complete activities of daily life.

Develop an individual plan for discharge based on the services required by the patient
Involve hospital case workers and start planning early in the admission process
Discuss the plan in detail with the patient

Includes patient name, ID number, date of note, date of admission, and date of discharge
Lists admitting and discharge diagnoses, attending or ward team, and surgical procedures/diagnostic tests performed
Brief history and pertinent physical exam and laboratory data, including past medical history, surgical history, medications, allergies, and social and family history
Hospital course, including daily progress notes, evaluation, labs, treatment, and outcome of treatment
Discharge condition and disposition (where the patient is being discharged to)

Provide patient education on new medications and updates
Educate patient on diet, activity instructions, wound care, rehabilitation services, and follow-up appointments
Educate patient on return precautions and when to call the doctor/PA

Communicate with the patient and in the discharge summary
Clear communication to primary care provider (typically via discharge summary)
Ensure adequate/close follow-up upon hospital discharge is scheduled with appropriate providers/services