Please help me to write discharge planning for a patient. 62 year old women with medical history significant for MS, DM2, HDL, ESRD s/p AV graft and s/p kidney transplant 2014, initially admitted to Neurology for evaluation of 3 week history of bilateral lower extremity weakness consistent with Multiple Sclerosis relapsi later transferred to ID service for treatment of E. Coli Bacteremia (resolved s/p treatment with Meropenem) and ongoing management of Meningitis. She’s on Bed rest. Husband is by her side. Discharge Planning (Write out in Narrative Format) Include: 1. What is anticipated date for discharge? 2 Interdisciplinary team plan members involved in discharge plan: ie. Social worker, physical therapy, care coordinator, family / patient 3. Who will be assisting patient upon discharge? Family, friends, homecare, rehab, ECF 4. If referral made, when will discipline visit, what care will be provided? 5. Complete a needs assessment: o What equipment will patient need? o How did you determine what needs are? o Are there safety issues or self-care issues? o How did you address these? 6. What health teaching was provided? o Dietary, Wound care, Activity, Medication administration (subQ injections) o Who provided teaching? o Who received the education? (family, patient, friend, caregiver, ECF) o When was teaching provided? o Strategies for teaching used ? Verbal, written, video, demonstration, return demonstration 7. Was teaching effective? o How do you know? ? Patient verbalized, returned demonstration 8. Were there any dietary changes or restrictions? o What were changes? 9. Were there medication dosage / frequency changes or new medications ordered for discharge? 10. Where does the nurse anticipate patient will follow-up on discharge? 11. When would the nurse anticipate patient to follow-up? 12. What type of follow-up does the nurse anticipate? PCP, Specialist, Labs, Chemo
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