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Discharge summaries

Long-Term Care Nursing Advisor, April 9, 2005

For planned discharges, federal regulations require that facilities complete a

• recapitulation of the resident's stay
• final summary of the resident's status based on the comprehensive assessment
• post-discharge plan of care

The post-discharge plan of care serves as discharge instructions for a resident dishcarging home or as the transfer form for a resident discharging to another healthcare facility. As a standard, a transfer form should be completed when transferring the resident to a hospital or to another healthcare facility.

At a minimum, include the following in the post-discharge plan of care:

• A description of the resident and familly's preference of care
• How the resident and family will access the services
• How care should be coordinated if continuing treatment involves multiple caregivers

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