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Discharge Planning, Transfer and Discharge Summaries, and Completion of Discharged Records

Sets out how the Agency plans each patient’s discharge from the start of care (the discharge and referral plan in the plan of treatment, 22 CCR §74697(b)(12)); involves social workers (§74713(c)(6)); records the discharge statement with the date, reason, and condition on discharge (§74735(a)(9)); completes the records of discharged patients within 30 days (§74731(c)); and, if the Agency is Medicare-certified, runs an effective discharge planning process using quality and resource use data (42 CFR §484.58), sends the discharge summary within 5 business days and transfer summaries within 2 business days (§484.110(a)(6)), and updates the comprehensive assessment at discharge (§484.55(d)(3)).

Preview: full text with a package
About this policy
Policy number
CA-HH-DC-01
Version
1.0
Main rule
42 CFR §484.58
Library
California home health · 58 policies
Category
Service delivery
Sections
19

In short

  • Plan for discharge from the first day: teach the patient and family so they can manage on their own.
  • If a patient goes to the hospital or another provider, send the transfer summary within 2 business days.
  • When a patient is discharged, write the date, the reason, and the patient’s condition in the record.
  • The discharge summary goes to the patient’s doctor within 5 business days.
  • Finish all notes and signatures quickly. The whole record must be complete within 30 days of discharge.

What's inside

19 sections. The full text comes with the One-time Policy Pack.

Full text with a package
  • Terms of Reference
  • 1. Purpose
  • 2. Scope
  • 3. Definitions
  • 4. Policy Statement (42 CFR §484.58)
  • 5. Planning Discharge From the Start of Care
  • 6. Deciding on Discharge
  • 7. Helping the Patient Choose a Post-Acute Provider
  • 8. The Discharge Visit
  • 9. Transfers
  • 10. The Discharge Statement and Discharge Summary
  • 11. Completing the Record
  • 12. Responsibilities
  • 13. Records and Compliance Monitoring
  • 14. Staff Training
  • 15. References
  • 16. Related Policies and Forms
  • 17. Approval
  • 18. Revision History

An inspector may ask

  • Show me the discharge and referral plan in this patient’s plan of treatment.
  • Show me the discharge statement for a recently discharged patient: date, reason, and condition on discharge.

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