Ensure clear documentation of patient handoff and discharge

Hospitals must continue to meet the Conditions of Participation outlined in Interpretive Guidelines in Appendix A of the CMS' State Operations Manual (SOM), notes Frank Ruelas, a patient safety professional and Health Insurance Portability and Accountability Act (HIPAA) consultant who founded HIPAA College in Arizona.

“Appendix A requires that all patients have a discharge plan. Essentially, the discharge plan takes into account the patient’s health condition and general situation, which in turn helps formulate the discharge planning process for an individual,” he says.

A patient encounter such as this may help facilities focus reviews of their own process for handling emergency department (ED) patients. Here are two key questions facilities should ask, according to Ruelas:

  • Can we show for every patient that presents in the ED a clear pathway from when the patient presented to the time the patient was discharged?
  • Can we show that the discharge of the patient was consistent with our assessment of the patient’s condition and the patient’s present situation?

Documentation, while often considered onerous, can be your friend, especially in the aftermath of cases involving patients with difficult needs.

This is “an area that lends itself easily to a very straightforward and meaningful audit. The audit can determine if a discharge plan was in place and documented for the patient, to include such contingencies [as] whether the patient refused care, was noncompliant, abusive, cooperative, or other factors that may impact a person’s willingness to participate in the development of their discharge plan,” Ruelas says.