sign130

Evidence has also suggested the potential for increased carer and patient stress levels and lack of integration
back into family, community and activities of daily living if there were no planned discharge in place. 51
It may be helpful to consider planned discharge as a specific and distinct phase following on from acute
care, post-acute care and linked to improved community reintegration. Such phases should be linked in a
planned manner, appropriate to each NHS area. 186
D Planned discharge from inpatient rehabilitation to home for patients who have experienced an
ABI provides beneficial outcomes and should be an integrated part of treatment programmes.
SIGN 118 on Management of patients with stroke: rehabilitation, prevention and management of complications,
and discharge planning includes the following evidence statement and good practice point on discharge
planning. 5
Discharge planning should be documented in a discharge document. Discharge documents may be paper
or electronic (eg in Electronic Clinical Communications Implementation format). See SIGN 128, the SIGN
discharge document for further advice on discharge documentation. 188
The following information should be accurately and legibly displayed in the discharge documents:
y Diagnoses
y Investigations and results
y Medication and duration of treatment if applicable
y Levels of achievement, ability and recovery (including patient goals and outcome measures)
y Team care plan
y Further investigations needed at primary care level with dates
y Further investigations needed at hospital and dates
y Further hospital attendance with dates (including follow-up therapy and review arrangements)
y Transport arrangements
y The hospital name, hospital telephone number, ward name or number, ward telephone number
y Consultant’s name and named nurse
y The date of admission and discharge.
Consideration should be given to such information being retained by the patient as a patient-held record,
to allow all members of the primary care team, allied health professionals (AHPs) and care agencies to see
clearly what the care plan for the patient should be. The wishes of the patient in respect of the confidentiality
of this record should be paramount. There is evidence that patient-held records may enhance the patient’s
understanding and involvement in their care. 189 There is also evidence to show that discharge planning
increases patient satisfaction. 190
10.4.2 PRE-DISCHARGE
At the time of discharge, the discharge document should be sent to all the relevant agencies and teams.
The following evidence statements and recommendations are drawn from SIGN 118. 5
10 • Service delivery
Pre-discharge home visits performed by various members of the multidisciplinary team (usually an
occupational therapist) aim to give staff (hospital and community), patients and carers the opportunity to
identify actual and likely problems, as well as to address any other needs that the patient/carer may have.
The Uk College of Occupational Therapists defines a home visit as a visit to the home of a hospital inpatient
which involves an occupational therapist in accompanying the patient to assess his/her ability to function
independently within the home environment or to assess the potential for the patient to be as independent
as possible with the support of carers. 191
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