99238 Hospital discharge day management; 30 minutes or less

Name of the Procedure:

Hospital Discharge Day Management; <30 minutes

Summary

This is a process where the healthcare team ensures a patient is ready to leave the hospital and continue recovery at home or another care facility. It includes a final check-up, medication review, and providing discharge instructions and follow-up care plans.

Purpose

To confirm that a patient is medically stable to leave the hospital and to ensure they have the necessary resources and instructions for continued care outside the hospital.

Indications

• Patients who have completed their treatment and are medically stable.
• Patients who have a plan in place for follow-up care.
• Adequate support systems available for the patient post-discharge.

Preparation

• Ensure that the patient understands the discharge process.
• Review and finalize any pending medical tests or consults.
• Confirm medication plans and provide prescriptions if necessary.

Procedure Description

1. The healthcare team reviews the patient's medical record for treatment completion.
2. A final check-up is performed, including vital signs and symptom assessment.
3. The team discusses the discharge plan with the patient and their family, including medication instructions and follow-up appointments.
4. Necessary documents, such as discharge summaries and prescriptions, are prepared.
5. The discharge nurse provides education on home care, including diet, activity restrictions, and signs of potential complications.
6. Arrange transportation if required.

Duration

Typically takes 15-30 minutes.

Setting

Performed at the hospital, usually in the patient's room.

Personnel

• Primary care physician or attending physician
• Registered nurse (discharge nurse)
• Pharmacist (for medication review)
• Discharge coordinator or case manager

Risks and Complications

• Risk of incomplete understanding of discharge instructions.
• Potential for medication errors or omissions.
• Readmission to the hospital if discharge is premature.

Benefits

• Reduces hospital stay duration, minimizing exposure to hospital-associated infections.
• Ensures a smooth transition to home or another care setting.
• Provides patients with clear instructions for continued recovery.

Recovery

• Follow the prescribed home care plan.
• Schedule and attend follow-up appointments.
• Monitor for any signs of complications and inform healthcare providers as needed.

Alternatives

• Extended hospital stay until ready for discharge without the need for a formal discharge procedure.
• Transfer to a rehabilitation facility or long-term care if intensive post-hospital care is required.

Patient Experience

The patient may feel anxious about leaving the hospital but will feel reassured by the provided instruction and support. Pain management and comfort measures will be addressed before discharge to ensure a smooth transition.