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CMW Tip of the Week: Properly document discharge plans

Case Management Weekly, November 12, 2008

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This week’s tip, an “Ask the Expert,” is provided by Karla Mariska, RN, a utilization review nurse at Marcus Daly Memorial Hospital in Hamilton, MT. The answer is provided by Jackie Birmingham, RN, BSN, MS, CMAC, author of Discharge Planning Guide: Tools for Compliance.

Q: What method of documentation is correct/legal on the discharge planning sheet everyone signs during discharge planning? Does entering ‘Continue medical work-up/care’ day after day really cut it, or should the notations be more specific?

A: In my non-legal opinion, the answer is NO. If the patient is in acute care, there must be some documentation of progress toward goals of the previous plan, evidence of medical necessity for continued stay, and what the next steps will be. You may want to structure the sheet that everyone signs in such a way that the basic questions are being addressed. Use the SBAR format grid: Situation, Background, Assessment, and Recommendation. Short statements in each category by everyone involved in the plan of care should meet expectations.

Example: Social worker note:

• Situation: Mrs. Jones’ discharge planned for SNF rehab.
• Background: family contacted, patient counseled about need for short-term rehab, bed available in Greenwood Nursing home for Friday.
• Assessment: discharge plans ready when patient medically cleared.
• Recommendation: contact Greenwood with update.

Have a tip or tool you’d like to share? Or maybe a question for our experts? E-mail it to editor Julie McGinley at jmcginley@hcpro.com.Your thoughts could be featured in the next issue of Case Management Weekly!

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