Nursing Discharge Note: 3 Best Practices for Facilities

The process of discharging a resident from a skilled nursing facility (SNF) to their home is complex and typically involves extensive coordination with home health services. Residents are often nervous about the transition, and it’s a chaotic time for the staff to orchestrate a plan of care that meets every need. Writing a nursing discharge note that captures the plan and meets guidelines can feel overwhelming.

One review of discharge documentation showed that 31% of SNFs did not meet the requirements established by the Centers for Medicare and Medicaid Services (CMS). Unclear or missing documentation can result in claim denials and loss of reimbursement for your organization. Many nurses — and facilities — are unsure of what information needs to be included in a discharge note.

In this article, we’ll discuss the purpose of the patient discharge summary and review CMS guidelines for documentation. We’ll also offer some best practices that your facility can adopt to give your staff confidence in completing discharge summary documentation.

Patient Discharge Summary Guidelines

To adequately plan for this time of transition, many facilities operate by the adage, “Discharge planning begins at the time of admission.” Starting a resident’s stay with the end in mind helps your team to anticipate discharge needs and proactively provide education and address concerns along the way.

The purpose of the discharge summary is to ensure continuity of care and a safe return home for the resident. The nursing discharge note is just one part of the discharge summary, which often involves multiple disciplines and staff. Your facility will choose what role nursing documentation plays in meeting discharge guidelines.

Here are five best practices to help your SNF organize and standardize the nursing discharge note.

1. Define Roles and Standardize Documentation

Every organization has unique needs and circumstances that require customized documentation for discharge planning. Your facility must decide which clinicians will document the various parts of the discharge summary and clearly communicate these expectations through training and written policy.

When making documentation decisions, consider the varying roles and scopes of practice of your clinicians (e.g., physician, nurse practitioner, LVN, and case manager). Also, be sure to follow any applicable state or regulatory guidelines. Planning is an interdisciplinary process and requires the use of a standardized form or template to clarify the division of responsibilities.

2. Align Patient Discharge Summary With Medicare

According to CMS guidelines, a SNF must have a plan for discharge when they anticipate the discharge of a resident to another care facility or home. To ensure coordination of care and a safe transition of the resident to their new environment, Medicare requires facilities to complete a discharge summary. To be compliant with CMS, the patient discharge summary must include:

• A summary of the resident’s stay
• A summary of the resident’s status at the time of discharge
• A post-discharge plan of care

Make sure the template your facility develops addresses each component clearly. Many electronic health record (EHR) systems have pre-built discharge templates available and ready for use. Regardless, be sure to review any forms or templates closely to make sure they meet requirements and are customized to the specific needs of your organization.

Other resources to guide discharge summary documentation include the Agency for Healthcare Research and Quality (AHRQ)’s Care Transitions from Hospital to Home: IDEAL Discharge Planning tool and the Re-Engineered Discharge (RED) Toolkit. Although originally designed for hospital-based settings, both tools have been successfully adapted for use by SNFs.

3. Address All Components of the Post-Discharge Plan of Care

Alarmingly, one of the most frequently overlooked parts of the discharge summary is the post-discharge plan of care. This is arguably the most important part of discharge planning and the documentation is essential for communicating plans for follow-up care. According to Medicare, the post-discharge plan of care must address:

• The resident’s and family’s/caregivers’ preferences for care
• How the resident and family/caregivers will access these services
• How care will be coordinated if continuing treatment involves multiple caregivers
• What education or instructions are provided to the resident and family/caregivers

Since nurses are so heavily involved in these aspects of care, many organizations use the post-discharge plan of care as a template for nursing discharge notes. It’s crucial to involve the resident and their family/caregivers in discharge planning. Doing so improves patient outcomes, reduces unplanned readmissions, and increases resident satisfaction.

Nursing Discharge Note Examples

Now that we’ve reviewed best practices for approaching the discharge summary, let’s take a look at two sample nursing notes, starting with one that fails to meet best practices.

Bad Example

“Resident understands plan of care. Condition is stable. All resident needs met at this time.”

Evaluation:

• How did the resident show “understanding?” If education was provided, what topics were covered and what was their response? Did they return demonstrate the skills?
• There is no indication of family/caregiver involvement. Did they participate?
• What cares were coordinated? Have home health services been arranged? When are follow-up appointments?
• This example is brief and incomplete, with vague wording throughout. Unless another clinician documented all of the required elements, this would not be adequate.

Good Example

“Discharge instructions reviewed with resident and his daughter at the bedside. Resident is alert and oriented — appears eager for discharge, stating, “I just can’t wait to get back home.” Dressing to left hip is clean, dry, and intact. Reviewed home medications including coumadin, fluoxetine, and prn ibuprofen and tylenol — resident verbalized understanding. Discussed purpose, how/when to take, side effects, and safe monitoring of each medication — gave handouts for each medication. Resident given education and handouts on fall and hip precautions — return demonstrates use of pillow between legs when sleeping and verbalizes understanding to avoid bending at the hip past 90 degrees. Daughter active and involved with education, asking appropriate questions. Daughter lives 1/2 mile from resident and will be checking on him daily in the morning. Home health services arranged through X for daily assistance walking and bathing — first visit tomorrow, xx/xx/xx at xx:xx. Resident records and summary faxed to home health today at xx:xx. Follow-up appointment with PCP, Dr. X, confirmed for xx/xx/xx at xx:xx. Daughter available to take resident to appointment. ”

Evaluation:

• There isn’t a summary of the resident’s stay at the facility, which can be ok if it’s included somewhere else in the summary.
• There is specific wording used throughout.
• Follow-up appointments are clear.
• Resident response and daughter involvement are described.

Looking for More Ways to Boost Documentation?

Now that we’ve covered the basics of a nursing discharge note, you might be interested in learning more documentation tips. We’re here to help — the IntelyCare newsletter is full of free healthcare facility tips, news, and strategies, shared right to your inbox.