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Patient discharged from an inpatient facility (eg, hospital, skilled nursing facility, or rehabilitation facility) within the last 60 days (GER)

CPT4 code

Name of the Procedure:

Patient Discharged from an Inpatient Facility (Hospital Discharge)


Hospital discharge is the process by which a patient is officially released from a hospital or other inpatient facility to return home or to another type of care, such as a skilled nursing facility. This process ensures that all medical, logistical, and supportive measures are in place for the patient's continued recovery and well-being.


Medical Condition or Problem it Addresses:

Hospital discharge occurs once the patient has recovered sufficiently from the acute phase of their illness or injury and can continue their recovery outside of the inpatient setting.

Goals or Expected Outcomes:
  1. Safe transition from the hospital to home or another care facility.
  2. Continuation of appropriate medical care.
  3. Prevention of readmission.


Specific Symptoms or Conditions Warranting the Procedure:
  • Patient's medical condition has stabilized.
  • Completion of the required treatment.
  • Patient no longer requires intensive medical monitoring.
Patient Criteria or Factors:
  • Ability to manage prescribed medication and follow-up care.
  • Presence of adequate support system at home or another facility.
  • Patient education and comprehension of discharge instructions.


Pre-procedure Instructions for the Patient:
  • Patients may need to arrange transportation to their next destination.
  • Schedule follow-up appointments.
  • Obtain necessary prescriptions and medical supplies.
Diagnostic Tests or Assessments Required:
  • Final medical evaluations to ensure readiness for discharge.
  • Assessment by healthcare professionals to confirm patient stability.

Procedure Description

Step-by-Step Explanation:
  1. Medical Clearance: Final assessments and approvals by attending physicians.
  2. Discharge Planning: Coordination with discharge planners or case managers.
  3. Patient Education: Providing instructions on medication, follow-up care, and lifestyle modifications.
  4. Documentation: Completion of discharge paperwork and summary.
  5. Arrangements: Facilitation of necessary home health services or transfer to another facility.
  6. Final Check: Ensuring patient or caregivers understand the instructions.
Tools and Equipment Used:
  • Medical records and discharge paperwork.
  • Prescriptions and medical supplies.
Anesthesia or Sedation Details:

Not applicable.


The discharge process can take a few hours, depending on the complexity of the case and the coordination required.


An inpatient facility such as a hospital, skilled nursing facility, or rehabilitation facility.


Healthcare professionals include:

  • Physicians
  • Nurses
  • Discharge planners or case managers
  • Pharmacists

Risks and Complications

Common Risks:
  • Misunderstanding of discharge instructions.
  • Errors in medication administration.
Rare Risks:
  • Sudden worsening of the patient's condition leading to readmission.
Possible Complications and Their Management:
  • Close follow-up and open communication channels with healthcare providers to manage potential complications.


Expected Benefits:
  • Patients recover in a more comfortable, familiar environment.
  • Reduced risk of hospital-acquired infections.
How Soon They Might be Realized:
  • Immediate transition to a less restrictive setting.
  • Faster mental and physical recovery outside of the hospital.


Post-Procedure Care and Instructions:
  • Adherence to prescribed medications and treatments.
  • Follow-up appointments with healthcare providers.
  • Monitoring for any new or worsening symptoms.
Expected Recovery Time:

Varies based on the individual patient’s condition and overall health status.

Restrictions and Follow-up Appointments:

Patients may need to limit physical activity, follow specific dietary plans, and attend follow-up visits to monitor progress.


Other Treatment Options Available:
  • Prolonged inpatient stay if the patient is not yet stable for discharge.
Pros and Cons of Alternatives:
  • Prolonged Stay: Continued close medical monitoring but increased risk of hospital-acquired infections and higher healthcare costs.
  • Earlier Discharge: Quicker return to home but may risk premature discharge if not properly assessed.

Patient Experience

During the Procedure:
  • Patients typically feel relief and eagerness to return home.
  • May experience some anxiety about managing care independently.
Pain Management and Comfort Measures:
  • Comprehensive education to alleviate concerns.
  • Support from family, home healthcare services, and ensuring easy access to healthcare providers for questions or issues.

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