Discharge Planning, Transfer, and Discharge and Transfer Summaries
Requires discharge planning from the start of care, help in choosing a post-acute provider using quality and resource-use data, a discharge assessment, and a discharge summary that gives an overall summary of services and the date and reason for discharge, sent to the follow-up practitioner within 5 business days; a transfer summary sent within 2 business days of a planned transfer or of learning of an unplanned one; and documentation of the date and reason whenever one service ends while others continue.
About this policy
- Policy number
- NC-HH-DC-01
- Version
- 1.0
- Main rule
- 42 CFR §484.58
- Library
- North Carolina home health · 57 policies
- Category
- Service delivery
- Sections
- 22
In short
- Plan for discharge from the first visit and teach the patient and family what they need to manage at home.
- Help patients choose a nursing facility or another agency using quality data, and respect their choice.
- Send the discharge summary to the patient’s follow-up doctor within 5 business days.
- Send a transfer summary within 2 business days of a planned transfer or of learning of a hospital admission.
- When one service ends but others continue, write down the date and reason.
What's inside
22 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (42 CFR §484.58; 42 CFR §484.110(a)(6); 10A NCAC 13J .1402(a)(2)(D))
- 5. Discharge Planning From the Start of Care
- 6. Helping the Patient Choose a Post-Acute Provider
- 7. The Discharge Assessment and Visit
- 8. Discharge Summary
- 8.1 Content
- 8.2 Sending it
- 9. Transfer Summary
- 10. When One Service Ends and Others Continue
- 11. Death of a Patient
- 12. Reasons for Discharge in the Annual Evaluation
- 13. Responsibilities
- 14. Records and Compliance Monitoring
- 15. Staff Training
- 16. References
- 17. Related Policies and Forms
- 18. Approval
- 19. Revision History
An inspector may ask
- This patient was discharged last month. Show me the discharge summary and when you sent it to the primary care practitioner.
- This patient went to the hospital unexpectedly. When did you learn of it, and when did you send the transfer summary?
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