Discharge Planning Bundle: Checklists, Scripts, and Follow-up Workflows

Purpose and how to use this bundle

This bundle provides reusable, editable components your team can adopt and tailor: a standard discharge checklist, a patient-facing discharge script with teach‑back prompts, a risk‑stratified post‑discharge follow‑up workflow, a basic measurement pack, and clear implementation notes (roles, documentation fields, and audit schedule). Copy this template into your site or unit domain, adapt the fields to your EHR and local workflows, pilot with one service line, and refine with measured feedback.

What’s included

• Standard discharge checklist (grouped items: identification, meds reconciliation, equipment & home needs, appointments, red‑flag instructions, documentation)
• Patient‑facing discharge script and teach‑back prompts
• Post‑discharge follow‑up workflow with practical risk stratification and timing
• Measurement pack: KPI definitions and a simple sampling plan
• Implementation notes: roles, documentation fields, audit cadence, tailoring guidance for high‑risk patients

Standard Discharge Checklist (editable)

Use this checklist as the unit’s required minimum. Mark responsible role and timestamp each item in the EHR.

Patient & encounter basics

• Verify patient identity and contact information (name, DOB, preferred phone, caregiver contact)
• Confirm primary diagnosis, reason for admission, and diagnosis at discharge
• Document discharge destination (home, skilled facility, rehab) and expected level of support

Medication reconciliation (required)

Use a structured medication reconciliation section in the chart. Capture:

• Pre‑admission/home medication list (what the patient was taking before admission)
• Current inpatient medications and changes made (stopped, started, dose changes)
• Discharge medication list (final list to take at home) with indication for each med, dose, frequency, duration, and provider who authorized the change
• Clear documentation of which meds were stopped and why
• Check for high‑risk combinations and provide explicit monitoring plans where needed

Equipment & home needs

• Equipment to be provided (oxygen, walker, supplies) and who arranged it
• Home services needed (home health, PT/OT, wound care)—referral completed and first visit scheduled if required
• Assess and document social determinants that affect discharge (transportation, caregiver availability, medication affordability)

Follow‑up and appointments

• Follow‑up appointment scheduled (date, time, location, phone) and reason for follow‑up
• Primary clinician and contact for post‑discharge concerns

Red‑flag instructions & patient education

• Provide concise, prioritized red‑flag signs and instructions (when to seek urgent care and who to call)
• Give written instructions in preferred language and confirm patient/caregiver has a copy
• Complete teach‑back (see script below) and record outcome

Documentation sign‑offs

• Discharging clinician: name, role, timestamp
• Nurse completing bedside teaching: name, role, timestamp
• Medication reconciliation completed by (name/role) and time
• Follow‑up booking confirmed by (name/role) and time

Patient‑facing discharge script & teach‑back prompts (editable)

Use a compassionate, plain‑language script. Train staff to use it naturally and to document teach‑back results.

Post‑discharge follow‑up workflow (risk‑stratified)

Define a simple risk stratification rule so teams know who needs early, proactive outreach.

Suggested risk criteria (adjust locally)

• High risk: Age ≥75, ≥3 chronic conditions, polypharmacy (≥5 meds or new anticoagulant/insulin), recent prior 30‑day admission, cognitive impairment, limited caregiver support, heart failure, COPD on oxygen
• Medium risk: 1–2 chronic conditions with moderate support needs
• Low risk: Single issue, reliable supports, clear home plan

Recommended follow‑up timing and ownership

• High risk: Phone call within 24–48 hours by care navigator or RN; medication reconciliation check; home visit or telehealth within 72 hours if indicated; clinic appointment within 7 days.
• Medium risk: Phone call within 48–72 hours by nursing staff; clinic appointment within 7–14 days.
• Low risk: Phone call or automated check within 72–96 hours; clinic appointment per routine.

Simple follow‑up call script (editable)

1. Confirm patient identity and reason for the call.
2. Ask about understanding of medicines and whether prescriptions were filled.
3. Ask about red‑flag symptoms and whether any have occurred.
4. Confirm follow‑up appointments and transportation arrangements.
5. Document actions taken (education, referral, escalation) and time next steps.

Measurement pack (KPI definitions and sampling plan)

Start with a small set of KPIs you can reliably measure. Use these to track the bundle’s impact and to support rapid tests of change.

Core KPIs

• Readmission rate (30‑day) — all‑cause 30‑day readmissions per 100 discharges. Track by risk stratum.
• Timely follow‑up completion — percent of high‑risk patients contacted within 48 hours.
• Medication reconciliation accuracy — percent of sampled discharges with reconciled med list documented and verified.
• Teach‑back success rate — percent of patients who successfully demonstrate understanding on teach‑back.
• ED returns within 7 days — unplanned ED visits within 7 days of discharge.

Sampling & audit plan (starter)

• Weekly sample: review 10 high‑risk discharges for full checklist completion and reconciliation accuracy.
• Monthly dashboard: trend KPIs by service line, with drilldown to common failure modes.
• Quarterly deep dive: root cause review for readmissions and recurring issues; propose PDSA changes.

Implementation notes and role matrix

Clear ownership prevents the “unchecked checklist” problem. Below is a starter role mapping—adapt to local titles.

• Discharging clinician (MD/NP/PA): finalize discharge diagnosis and discharge medication orders; sign discharge summary.
• Bedside nurse: complete patient teaching and teach‑back; confirm equipment and home supports; document education and wound care instructions.
• Pharmacist / Pharmacy technician: perform medication reconciliation, counsel on high‑risk meds, and document counseling.
• Care navigator / case manager: arrange follow‑up appointments, home services, durable medical equipment, and conduct early post‑discharge outreach for high‑risk patients.
• Unit manager / quality lead: run audits, collect KPI data, and coordinate improvement cycles.

Documentation fields to include in the EHR (suggested)

• Discharge checklist completed (yes/no), completed by (name/role), timestamp
• Medication reconciliation status (complete/partial/not done), reconciled by
• Teach‑back completed (success/needs follow‑up), notes
• Follow‑up appointment details (date/time/location/provider)
• Risk level (high/medium/low) and assigned follow‑up owner

Tailoring guidance for high‑risk patients

High‑risk patients often need more than a checklist. Consider these additions:

• Automatic EHR flag for high risk that triggers a navigator assignment
• Medication delivery or community pharmacy coordination before discharge
• Home health referral with first visit within 48–72 hours
• Enhanced caregiver training and printed checklists for complex regimens

Common pitfalls and quick fixes

• Pitfall: checklist completed on paper but not in EHR. Fix: require digital sign‑off as part of discharge completion.
• Pitfall: unclear ownership of follow‑up calls. Fix: assign owner before patient leaves bedside and document in EHR.
• Pitfall: teach‑back treated as checklist box. Fix: train staff to use teach‑back as a conversation and record examples of patient responses.

Adopt, pilot, measure, and scale (practical steps)

1. Acquire the bundle into your domain and appoint an implementation lead.
2. Tailor checklists and risk criteria to your patient population and EHR fields.
3. Pilot on a single service line or shift for 4–6 weeks; collect baseline and pilot KPIs.
4. Run weekly audits, review results in huddles, iterate using small tests of change.
5. When stable, scale to other services and embed KPI reporting into routine dashboards.

Editable snippets (copy/paste)

Include these into your EHR templates or patient handouts:

Red‑flag example (patient handout): Call your doctor or go to the ED right away for: severe chest pain, new or worsening shortness of breath, sudden confusion or weakness, very high fever, uncontrolled bleeding.

Short meds reconciliation header: Medication name | Dose | How to take | Why taking | Who reviewed

Next opportunities (capability ideas)

Consider adding interactive checklists tied to submission storage, automated follow‑up reminders, and KPI dashboards. See CapabilityEnhancementNotes for details.